[Pulmonary cryptococcosis exhibiting diffuse multiple nodular shadows]

We report a case of pulmonary cryptococcosis showing diffuse multiple nodular shadows in all lung fields. A 39-year-old woman with no immunological abnormalities was admitted with complaints of cough and sputum. She had experienced measles 4 weeks prior to admission. Chest x-ray films revealed diffuse nodular opacities throughout the lung fields, a finding suggestive of metastatic lung cancer. Detailed examinations, including transbronchial lung biopsy, were not conclusive. A diagnosis of pulmonary cryptococcosis was made on the basis of findings from video-assisted thoracoscopic biopsy. Primary pulmonary cryptococcosis usually appears as a solitary nodule or limited infiltration. Immunologically compromised hosts commonly demonstrate various abnormal shadows, such as the multiple nodular shadows observed in our patient. It has been reported that measles infection can cause temporary immune suppression. Secondary immunodeficiency resulting from the preceding infection with measles could explain the unusual chest x-ray findings in this case.

[A case of ruptured P4 segment aneurysm of the posteior cerebral artery: therapeutic pitfalls encountered when dealing with the multiple intracranial aneurysms]

A P4 segment aneurysm of the posterior cerebral artery has rarely been described. A case of ruptured P4 segment aneurysm, which re-ruptured after clipping procedure for unruptured internal carotid artery aneurysm, was reported. A 57-old-man had sudden onset of severe headache and vomiting and was transferred to our hospital. CT scan on admission showed diffuse subarachnoid hemorrhage dominantly extending to the tentorial surface and the occipital interhemispheric tissue. Four-vessel angiography demonstrated a right internal carotid-posterior communicating artery junction aneurysm, and its neck clipping was performed on day 5. Intraoperative inspection of the whole appearance of the aneurysm was difficult because of the aneurysm existing on the ventral portion of the internal carotid artery and definite diagnosis of the bleeding source was not obtained. On day 23, he complained of severe headache and restricted vision and CT scan showed intracerebral hematoma in the left occipital lobe with intraventricular hemorrhage. The angiograms and CT scan on admission were reexamined, and another aneurysm on the left parieto-occipital artery (P4 segment) was retrospectively identified. The ruptured P4 segment aneurysm was obliterated via the interhemispheric approach and the patient enjoyed an uneventful postoperative course. When a thick subarachnoid hemorrhage distributed in the occipital interhemispheric fissure, quadrigeminal cistern, and ambient cistern is encountered, the existence of a possible P4 segment aneurysm should be suspected. Correct initial diagnosis and definite treatment of the ruptured lesion in the acute stage is essential in dealing with SAH-patient with multiple aneurysms. When they are unruptured lesions at a common aneurysm site, the existence of an unusually located aneurysm should not be overlooked as the possible source responsible for symptoms.

Is Enterobius gregorii Hugot, 1983 (Nematoda: Oxyuridae) a distinct species?

A series of 849 male pinworms collected from a 64-yr-old Japanese male was examined. They were classified by the spicule morphology into 87 Enterobius vermicularis (Linnaeus, 1758), 754 Enterobius gregorii Hugot, 1983, and 6 immature adults, whereas 2 worms lacked spicules. The worm length of E. vermicularis was significantly larger than E. gregorii. The shape and length of the distal tubular portion of the spicule were identical in these forms, whereas the basal portion was different. The immature adults just after the final molt or still within the cuticle of the fourth stage had only a distal tubular portion, indicating that the basal portion is added during subsequent development. Moreover, various transitional forms were observed in the spicule morphology in the worms with intermediate body size between E. vermicularis and E. gregorii, showing that the basal portion of the spicule of E. vermicularis develops after the completion of E. gregorii-type basal portion. It is suggested that E. gregorii is a young stage of E. vermicularis.

Symptomatic tonsillar ectopia

OBJECTIVE

To determine if slight descent of the cerebellar tonsils (< 5 mm below the foramen magnum; tonsillar ectopia) may cause surgically treatable symptomatology.

METHODS

A consecutive series of nine symptomatic patients with tonsillar ectopia seen between December 1990 and March 1993 are reported on. The same number of age and sex matched controls were selected at random from outpatients. Twelve asymptomatic subjects with tonsillar ectopia were found among 5000 people between January 1991 and March 1996. Diagnosis of tonsillar ectopia was based on midsagittal MRI.

RESULTS

Patients presented mainly with chronic intractable occipital dull pain, vertigo, and dysequilibrium. In all patients MRI showed normal brain structure except for tonsillar ectopia (-2.9 (SD 0.8) mm), which has historically been thought to be of no clinical relevance. In the control group the tonsilar position was +2.1 (SD 2.8) mm (p<0.01). Neurotologically abnormal findings were detected with a monaural speech integration test (100%), eye tracking test (56%), optokinetic nystagmus test (89%), and visual suppression test (67%) which strongly suggested a CNS lesion. In accordance with the results of MRI and precise neurotological examination, posterior fossa decompression surgery was carried out, followed by improvement of preoperative symptoms and less severity of neurotological abnormalities in all patients.

CONCLUSION

Tonsillar ectopia could cause neurological symptoms in small populations, which were surgically treatable. Neurotological assessment was necessary to verify the aetiological relation between tonsillar ectopia and various symptoms.

[A case of adenoid cystic carcinoma presenting with stridor and which was treated by reversed gamma type stent placement]

A 66-year-old man was admitted to Saiseikai Suita Hospital with stridor and dyspnea. The flow-volume curve showed central airway obstruction pattern. Although a P-A chest roentogenogram was normal, chest tomogram demonstrated a tumor shadow in the lower portion of the trachea. Chest CT examination demonstrated a tumor arising from the posterior wall of the lower portion of the trachea and stenosis with wall thickening extending from the lower portion of the trachea to both main bronchi. Bronchofiberscopic examination revealed polypoid tumors obstructing the lower portion of the tracheal lumen, and biopsy was subsequently performed. On the night immediately after the bronchofiberscopic examination, the patent suddenly choked, and emergency intubation was performed. Adenoid cystic carcinoma was diagnosed on biopsy and we decided to place a spiral Z-stent. A reversed gamma-type stent placement was used. The first spiral Z-stent extended from the trachea to the right main bronchus and the second spiral Z-stent was placed in the left main bronchus through the first stent. Following the spiral Z-stent placement radiotherapy was performed. Spiral Z-stent placement resulted in dilation of the stenotic trachea and both main bronchi.

Middle cerebral artery blood velocity depends on cardiac output during exercise with a large muscle mass

We tested the hypothesis that pharmacological reduction of the increase in cardiac output during dynamic exercise with a large muscle mass would influence the cerebral blood velocity/perfusion. We studied the relationship between changes in cerebral blood velocity (transcranial Doppler), rectus femoris blood oxygenation (near-infrared spectroscopy) and systemic blood flow (cardiac output from model flow analysis of the arterial pressure wave) as induced by dynamic exercise of large (cycling) vs. small muscle groups (rhythmic handgrip) before and after cardioselective beta 1 adrenergic blockade (0.15 mg kg-1 metoprolol i.v.). During rhythmic handgrip, the increments in systemic haemodynamic variables as in middle cerebral artery mean blood velocity were not influenced significantly by metoprolol. In contrast, during cycling (e.g. 113 W), metoprolol reduced the increase in cardiac output (222 +/- 13 vs. 260 +/- 16%), heart rate (114 +/- 3 vs. 135 +/- 7 beats min-1) and mean arterial pressure (103 +/- 3 vs. 112 +/- 4 mmHg), and the increase in cerebral artery mean blood velocity also became lower (from 59 +/- 3 to 66 +/- 3 vs. 60 +/- 2 to 72 +/- 3 cm s-1; P < 0.05). Likewise, during cycling with metoprolol, oxyhaemoglobin in the rectus femoris muscle became reduced (compared to rest: -4.8 +/- 1.8 vs. 1.2 +/- 1.7 mumol L-1, P < 0.05). Neither during rhythmic handgrip nor during cycling was the arterial carbon dioxide tension affected significantly by metoprolol. The results suggest that as for the muscle blood flow, the cerebral circulation is also affected by a reduced cardiac output during exercise with a large muscle mass.

Transitions between blocked and zonal flows in a rotating annulus with topography

The mid-latitude atmosphere is dominated by westerly, nearly zonal flow. Occasionally, this flow is deflected poleward by blocking anticyclones that persist for 10 days or longer. Experiments in a rotating annulus used radial pumping to generate a zonal jet under the action of the Coriolis force. In the presence of two symmetric ridges at the bottom of the annulus, the resulting flows were nearly zonal at high forcing or blocked at low forcing. Intermittent switching between blocked and zonal patterns occurs because of the jet's interaction with the topography. These results shed further light on previous atmospheric observations and numerical simulations.

Huntington's disease gene product, huntingtin, associates with microtubules in vitro

The gene responsible for Huntington's disease produces a large protein with a molecular weight of approximately 350 k, designated huntingtin. Here, we report that the protein can associate in vitro with the microtubules. Through the process of assembly and disassembly of microtubules, both wild-type and mutant huntingtin associate with microtubules to almost the same degree. Huntingtin does not bind to the tubulin-affinity column directly. Huntingtin appears to interact with polymerized tubulin. These results suggest that huntingtin may have a role in intracellular organelle transport or axonal transport by its association with microtubules.

Middle cerebral artery blood velocity, arterial diameter and muscle sympathetic nerve activity during post-exercise muscle ischaemia

During exercise the transcranial Doppler determined mean blood velocity (Vmean) increases in the middle cerebral artery (MCA) and reflects cerebral flood flow when the diameter at the site of investigation remains constant. Sympathetic activation could induce MCA vasoconstriction and in turn elevate Vmean at an unchanged cerebral blood flow. In 12 volunteers we evaluated whether Vmean relates to muscle sympathetic nerve activity (MSNA) in the peroneal nerve during rhythmic handgrip and post-exercise muscle ischaemia (PEMI). The luminal diameter of the dorsalis pedis artery (AD) was taken to reflect the MSNA influence on a peripheral artery. Rhythmic handgrip increased heart rate (HR) from 74 +/- 20 to 92 +/- 21 beats min-1 and mean arterial pressure (MAP) from 87 +/- 7 to 105 +/- 9 mmHg (mean +/- SD; P < 0.05). During PEMI, HR returned to pre-exercise levels while MAP remained elevated (101 +/- 9 mmHg). During handgrip contralateral MCA Vmean increased from 65 +/- 10 to 75 +/- 13 cm s-1 and this was more than on the ipsilateral side (from 63 +/- 10 to 68 +/- 10 cm s-1; P < 0.05). On both sides of the brain Vmean returned to baseline during PEMI. MSNA did not increase significantly during handgrip (from 56 +/- 24 to 116 +/- 39 units) but the elevation became statistically significant during PEMI (135 +/- 86 units, P < 0.05), while AD did not change. Taken together, during exercise and PEMI, Vmean changed independent of an elevation of MSNA by more than 140% and the dorsalis pedis artery diameter was stable. The results provide no evidence for a vasoconstrictive influence of sympathetic nerve activity on medium size arteries of the limbs and the brain during rhythmic handgrip and post-exercise muscle ischaemia.

Machado-Joseph disease gene product identified in lymphocytes and brain

Machado-Joseph disease (MJD) is associated with the expansion of an unstable CAG repeat. The existence of an abnormal gene product in MJD was previously suggested with the expanded polyglutamine stretch-specific antibody. However, the product of the normal allele has not previously been identified. We generated monoclonal antibodies against the fusion protein (codon 225-310) of the MJD gene product and then identified the MJD1 gene product in normal lymphoblastoid cells as a approximately 50-kDa protein by immunoblot analysis. The electrophoretic mobility differences among the normal allele products corresponds to the molecular size difference produced by the polyglutamine stretch and the polymorphism at the C-terminus. Moreover, abnormal immunoreactive bands which were larger than the normal ones were found as a approximately 60-kDa protein exclusively in the MJD samples. The cytoplasm and the nuclei of neurons and glial cells were stained by these antibodies with immunocytochemistry. As in other CAG repeat diseases, the abnormal and normal allele products were almost equally expressed in lymphoblastoid cells and the brain of MJD patients.

Double product response is accelerated above the blood lactate threshold

Catecholamine concentrations are known to increase sharply in the blood at work rates above the blood lactate threshold (LT); thus, we hypothesized that the double product (DP, heart rate-systolic blood pressure product) may also abruptly increase at work rates above the LT. Ninety healthy students performed a stepwise incremental test on a cycle ergometer. The slopes of the two regression lines below and above the LT for the heart rate (HR), the indirectly measured systolic blood pressure (SBP), and the DP, respectively, were compared using VO2 as an independent variable. For all three parameters the slope of the regression line above the LT was significantly higher than that below the LT. Although either the same or a lower slope was found in the HR (N = 23) or SBP (N = 22) responses in some subjects above the LT as compared with that below the LT, a steeper DP slope above the LT was evident in all 90 subjects. The same results were also obtained during 4-min constant work rate exercise sessions at a variety of submaximal intensities performed in a random order in seven subjects. In addition, we established the DP break point (DPBP) determining protocol with a fairly good test-retest reliability (r = 0.951) and a correlation coefficient between the DPBP and the LT (r = 0.900). These results suggest that the DP increases more steeply above the LT, and, as a result, the DPBP is considered to be a valid and useful parameter as a marker of the LT.

Failure of aged rats to accumulate eosinophils in allergic inflammation of the airway

To investigate the effect of aging on the allergic airway response, we examined the bronchoconstrictive responses and cellular inflammatory changes in a rat model of bronchial asthma by evaluating young and old animals. Two different age groups of Brown-Norway rats, actively sensitized by injection of ovalbumin into the foot pads, were used: 7 to 8 weeks old (young group) and 100 to 120 weeks old (aged group). Both the aged and young rats produced on ovalbumin-specific IgE antibody and exhibited an immediate asthmatic response after exposure to ovalbumin, but the degree of specific IgE antibody was significantly higher in young rats. The young group showed a marked increase in the number of eosinophils and neutrophils in bronchoalveolar lavage fluid 2 days after exposure to ovalbumin, whereas no eosinophilia was seen in the aged group. To evaluate the mechanism of the decreased accumulation of eosinophils in aged rats, cells from popliteal lymph nodes from ovalbumin-sensitized rats were incubated with ovalbumin for 48 hours. Although eosinophil chemotactic activity, determined by a modified Boyden chamber method, was present in the supernatant of cultured lymph node cells from young rats, it was absent from those of aged rats. In vivo administration of anti-IL-5 monoclonal antibody revealed that one of the factors of eosinophil chemotactic activity was IL-5. Lymph node cells from aged rats tended to produce greater amounts of interferon-gamma than did those from young animals. Findings indicate that aged rats have a defect in eosinophil accumulation in sites exposed to antigen, probably because of an age-dependent alteration in T cells.

Evans' syndrome associated with Graves' disease

A 36-year-old woman who had had Graves' disease for 6 years was admitted with severe thrombocytopenia. Evans' syndrome was diagnosed. The patient's family history showed multiple cases of Graves' disease but no cases of Evans' syndrome. Both conditions in this patient improved with corticosteroid and thiamazole therapy. Several autoimmune antibodies were found, but a common autoimmune mechanism was not clearly shown. Although the combination of Graves' disease and Evans' syndrome had not occurred previously in her family, genetic factors may play an important role in the pathogenesis of both conditions.

Impaired non-insulin mediated glucose uptake after downhill running in rats

To evaluate the effects of a single bout of exercise on non-insulin mediated glucose uptake in rats, hyperglycemic clamp tests were performed either 12 h after the rats were subjected to downhill running (90 min, -16 degrees incline, n = 10) or without any prior exercise (n = 10). Somatostatin (1.0 microgram/kg/min) was infused during clamps to suppress insulin secretion, while the serum glucose was clamped at a level of 200 mg/dl for 100 min. The serum insulin levels during the hyperglycemic clamp was maintained at basal levels. The non-insulin mediated glucose disposal rate was significantly decreased during clamp performed after downhill running (5.45 +/- 0.61 mg/kg/min) compared to the control conditions (9.63 +/- 0.32 mg/kg/min, P < 0.01). The creatine kinase level after downhill running (561 +/- 206 IU/l) was significantly higher than the control conditions (118 +/- 20 IU/l, P < 0.01). These results thus suggest that the muscle damage caused by downhill exercise, which predominantly consists of eccentric type, may therefore decrease the non-insulin mediated glucose uptake.

Sensory nerve supply in the human subacromial bursa

The subacromial bursa is the major component of the subacromial gliding mechanism. The neural elements of the subacromial bursa obtained from specimens that underwent autopsy and surgery were investigated by the silver impregnation and immunohistochemical methods with antisera to substance P and calcitonin gene-related peptide; which are considered to be involved in nociceptive transmission, and protein gene product 9.5. Free nerve endings, Ruffini endings, Pacinian corpuscles, and two kinds of unclassified nerve endings were observed. Most of these receptors were observed of the roof side of the coracoacromial arch, which is exposed to stress because of the impingement. A delta and C fibers, thought to be nerve fibers of free nerve endings, were immunoreactive to substance P and calcitonin gene-related peptide. On the other hand, thick fibers thought to originate in encapsulated mechanoreceptors were not immunoreactive to substance P. The subacromial bursa receives nociceptive stimuli and proprioception and seems to regulate appropriate shoulder movement.

[Evaluation of the retrosternal space and the retrocardiac space on normal left lateral radiographs of the chest]

Left lateral chest radiographs with normal studies were evaluated in 100 Japanese (50 females and 50 males) to compare the radiolucency of the retrosternal space (RSS) with that of the retrocardiac space (RCS) and to measure the RSS. In 56 (56%) cases, the RSS was equally radiolucent to the RCS. In 40 (40%) cases, the RSS was less radiolucent than the RCS (33 of 50 females and 7 of 50 males). The difference between the sexes was statistically significant (p = 0.0001). The RSS was more radiolucent than the RCS in only 4 (4%) males. Frontal chest radiographs of 50 females were classified into one of three groups (Small, Medium, or Large) depending on the size of soft tissue opacity of the breast. The differences between the radiolucency of the RSS and RCS were statistically significant between the Small and Medium and the Small and Large groups (both p < 0.0001). The strength of the relationship between the radiolucency and body-to-fat ratio was statistically significant (p = 0.0028). Results of data comparison between females and males remained significant when adjusted for differences in body-to-fat ratio (p < 0.0001). The distance on the chest radiograph from the sternum to the most anterior aortic border (the distance of RSS) could be measured on only 37 (37%) lateral chest radiographs, and the averages and standard deviations were as follows: 2.2 +/- 0.5 in all cases, 2.0 +/- 0.5 in females, and 2.4 +/- 0.5 in males. The difference between the sexes was statistically significant (p < 0.05). In conclusion, an RSS that is more opaque (less radiolucent) than the RCS is a frequent normal finding because of the opacity of the breast and fat tissue, especially in females, and the length of the RSS is shorter in females than in males.

[Two cases of therapy-related myelodysplastic syndrome]

Myelodysplastic syndrome (MDS) was sorted out two types; primary type and secondary type caused by irradiation or several drugs. Clinical features and chromosomal analysis were investigated in two patients with secondary MDS, caused by cyclophosphamide (CPM) or rifampicin (RFP) respectively, and fourteen cases of primary MDS hospitalized from 1988 to 1993. Two cases of secondary MDS progressed refractory anemia with excess of blasts (RAEB), however two of 14 patients with primary MDS progressed to acute leukemia. Median survival was similar in two groups. In cytogenitic analysis, complex abnormalities including -5/5q- and/or -7/7q- have two cases of secondary MDS and nine out of 14 cases of primary MDS. Complex chromosomal abnormalities did not improve following chemotherapy. In this study, clinical features and cytogenetic analysis demonstrated no significant difference between primary and secondary MDS.

A cervical dural arteriovenous fistula in a patient presenting with radiculopathy. Case report

A 51-year-old man presenting with radiculopathy a rare cervical dural arteriovenous fistula (AVF) is reported. Angiography revealed that the cervical dural AVF was fed mainly by the left C-3 and C-4 radicular arteries and drained into the internal vertebral venous plexus with no communication with intradural structures. The dural AVF was treated surgically after embolization therapy. Although the AVF showed mass effect on computerized tomography (CT) scanning, abnormal vessels, which were suspected to drain the AVF, were observed intraoperatively to compress the left C-4 and C-5 nerve root sleeves. After resection of these abnormal epidural vessels, monoparesis of the left proximal upper extremity was markedly improved. In this patient, dynamic CT scanning was useful in the initial diagnosis, and the preoperative embolization therapy was very effective.

Acute aortic dissection with intramural hematoma: possibility of transition to classic dissection or aneurysm

Acute aortic dissection with intramural hematoma has been believed to have a good prognosis, but we have encountered the transition of this entity to a classic dissection or aneurysm. We report the serial computed tomography (CT) features in 27 cases of acute aortic dissection with intramural hematoma. Eleven patients (40.7%) developed a classic dissection or aneurysm during follow-up. Four patients (14.8%) showed transition to a classic dissection without resolution of the intramural hematoma; each had a dilated ascending aorta measuring > 5 cm in diameter on the initial CT. One case (3.7%) developed an enlarging aneurysm without resolution of the intramural hematoma. In 19 cases (70.4%), the hematoma resolved; among these 19, the aortic diameter was significantly larger (p < 0.01) than those in a normal control group. Two of these 19 later developed an aneurysm, and four developed a classic dissection. This entity often (40.7%; 11 of 27) required surgical intervention or periodic follow-up CT examinations, particularly with a dilated ascending aorta of > 5 cm in diameter.

[Huntington's disease: trinucleotide disease or polyglutamine disease?]

Huntington's disease (HD) is associated with expansion of an unstable CAG repeat. Using antibodies against the synthetic peptide corresponding to the sequence of HD gene IT15, we have identified the HD gene product in normal lymphocytes as a approximately 350kDa protein by immunoblot analysis. Moreover, when a modified SDS-PAGE using a low concentration of methylenbisacrylamide was run longer, abnormal immunoreactive bands larger than normal ones were found exclusively in HD samples. We also found double bands in HD brain homogenate samples. Recently on the other CAG repeat diseases, such as SCA1 and DRPLA, abnormal gene products were also reported. These results demonstrate the existence of the expanded CAG repeat gene products and open a possibility that the expanded polyglutamine stretch may really participate in the pathological process of the CAG repeat diseases.

Monoclonal antibody against the polymorphic site distinguishes apolipoprotein E4 from other isoforms

Apolipoprotein E4 has been confirmed as a genetic risk factor for Alzheimer's disease. Although several hypotheses have been advanced to explain how the inheritance of apolipoprotein E isoforms affects the rate of Alzheimer's disease expression, the mechanism whereby apolipoprotein E is involved in the pathogenesis of Alzheimer's disease is still uncertain. To clarify the way in which the apolipoprotein E4 isoform differs from the others, we generated a monoclonal antibody specifically reactive with the apolipoprotein E4 isoform. This antibody suggests that the polymorphic site is important in differentiating the ApoE4 isoform from others.

[Effect of inhaled vancomycin hydrochloride on elimination of methicillin-resistant Staphylococcus aureus]

Vancomycin hydrochloride (VCM) is one of the most useful drugs in treating methicillin-resistant Staphylococcus aureus (MRSA) infections. Intravenous administration of the drug is, however, not appropriate in patients with impaired renal or liver function. Thus, we studied the effect of inhaled VCM on MRSA. Fifty-one patients with MRSA in their sputum (35 men and 16 women 21, in the "infected" group and 30 in the "colonized" group, mean age 76.4 years) were studied. MRSA was eliminated in 84.3% of the patients (43 of 51 patients), and the average time required for elimination was 14.7 days. MRSA colonization or infection recurred in 46.5% of the patients (20 of 43 patients), and the duration from elimination until recurrence of MRSA averaged 28 days. Eight patients in whom MRSA was not eliminated by inhaled VCM were not clinically distinguishable from other patients, but their performance status was worse. Two hours after VCM was inhaled, serum VCM concentrations were unmeasurable in 7 patients. The VCM level in sputum peaked at 262.5 micrograms/g just after inhalation, and then gradually decreased. No side effects of this treatment were observed. These results suggest that inhaled VCM can be used to eliminate MRSA.