Summer-type hypersensitivity pneumonitis

Summer-type hypersensitivity pneumonitis (SHP), the most prevalent type of HP in Japan, is caused by seasonal mold contamination in the home environment. The causative agent of the disease is Trichosporon cutaneum. The fungus grows in warm, moldy, decaying organic matter, and scatters in the air from the colonizing places. The inhaled fungi sensitize susceptible patients intratracheally and induce the disease. Glucuronoxylomannan of the fungus has a potent antigenicity that causes granulomatous alveolitis. Assay of anti-T. cutaneum antibody is very useful to establish the diagnosis of the disease because the antibody activity is virtually positive in all cases of the disease. Elimination of T. cutaneum from the colonizing places prevents recrudescence. SHP, a new form of HP, had been considered to be peculiar to Japan, but the first case of SHP outside Japan was identified in Korea last year. Soon it will be recognized in many countries of temperate and tropical clime.

Change in variant transthyretin levels in patients with familial amyloidotic polyneuropathy type I following liver transplantation

Three patients with familial amyloidotic polyneuropathy (FAP) type I underwent liver transplantation from heart-beating cadaveric donors. Since 2 patients underwent blood transfusion during the operation, variant transthyretin (TTR) levels in the plasma did not decrease time dependently. However, in 1 patient without blood transfusion variant TTR levels decreased in a time dependent manner and plasma half life of variant TTR was calculated to be 2.1 days. Total protein, normal, and variant TTR levels in cerebrospinal fluid (CSF) remained unchanged after liver transplantation.

[Transpericardial completion pneumonectomy with omental pedicle flap for chronic empyema caused by bronchiectasis]

A 61-year-old man received right middle and lower lobectomies for lung abscess caused by bronchiectasis in 1957. Since the right upper lobe was destroyed and multiple peripheral bronchopleural fistulae developed later, open thoracostomy was done in 1990. For this patient we performed transpericardial completion pneumonectomy with omental pedicle flap in 1993. He was complicated in a transient thoracic empyema. But he recovered by open drainage followed by surgical closure using Clagett's method and remains well 2 years after the radical operation. Transpericardial approach with omental pedicle flap though a median sternotomy seemed useful to prevent the postpneumonectomy bronchopleural fistula in this patient with thoracic empyema. But the primary closure of the empyema cavity should not be done, if dead space remains in the pleural cavity.

[A case of spontaneous hemopneumothorax occurred after thoracocentesis]

A 41-year-old man was admitted to our hospital complaining of severe right chest pain and dyspnea. Soon after, right thoracocentesis was done and pleural free air was aspirated. Twenty minutes later he fell into a shock status. Chest roentgenogram showed massive right pleural fluid collection. Chest drainage revealed that massive bleeding continued. Therefore, emergent thoracotomy was performed. Bleeding point was a ruptured stump of pleural adhesion of the apical parietal pleura. His postoperative course was almost good, and discharged on the tenth postoperative day. Careful observation after thoracic aspiration is necessary in the treatment of spontaneous pneumothorax.

Generation of free radicals from neocarzinostatin mediated by NADPH/cytochrome P-450 reductase via activation of enediyne chromophore

Neocarzinostatin (NCS) is one of the most potent antitumor agents. It contains a chromophore of a unique enediyne structure as its prosthetic group. Here, we report the generation of free radicals from NCS by the NADPH/cytochrome (cyt) P-450 reductase system. Free radical species, which were generated in the reaction mixture of NCS/NADPH/cyt P-450 reductase, were identified by using electron spin resonance spin trapping with 5,5-dimethyl-1-pyrroline N-oxide (DMPO). The spin adducts of superoxide and hydroxyl radical (DMPO-OOH and DMPO-OH, respectively) were generated in the reaction of NCS with the NADPH/cyt P-450 reductase system. From kinetic analyses of DMPO-OOH generation as a function of the concentration of NCS, the Vmax/Km value of the reaction was 0.4 x 10(6) M-1min-1. In addition, we identified thiyl radical generation in this system in the presence of glutathione. These results indicate that NCS is a potent generator of free radicals in cells where cyt P-450 reductase is available. Moreover, it seems that free radicals, generated by enzymatic activation of NCS, are involved in cytotoxicity of NCS as well as in DNA damage.

Multiple functions of nitric oxide in pathophysiology and microbiology: analysis by a new nitric oxide scavenger

A wide range of biological functions of nitric oxide (NO) was analyzed using a newly discovered nitric oxide scavenger, 2-phenyl-4,4,5,5-tetramethylimidazolineoxyl-1-oxyl-3-oxide (PTIO) or its water-soluble derivative carboxy-PTIO. The chemistry is very simple in that NO was oxidized by PTIO, yielding one mole each of NO2 and 2-phenyl-4,4,5,5-tetramethylimidazoline-1-oxyl. Based on the potent NO-scavenging activity of PTIO derivatives, the diverse functions of NO under physiological states as well as various pathological conditions such as endotoxin shock and viral diseases are now explicated. It was found that PTIO and carboxy-PTIO showed significant inhibitory activity against a series of biological actions of NO: (1) endothelium-dependent vascular relaxation in an ex vivo system, (2) pathogenicity of NO produced excessively in endotoxin shock in rats and in influenza virus pneumonitis in mice, and (3) enhanced vascular permeability in solid tumors mediated by NO. PTIO directly extinguishes NO generated by NO synthase (NOS) without affecting NOS activity, which is a clear contrast to NOS inhibitors. Therefore, characterization of this unique mode of action of PTIO appears to be helpful not only in understanding of the pathophysiological role of NO but also in the treatment of various diseases caused by excessive production of NO.

Prevalence of HBV and HCV infection in Japanese patients with hepatocellular carcinoma

The prevalence of hepatitis B virus (HBV) and hepatitis C virus (HCV) infection was investigated in 63 Japanese patients with hepatocellular carcinoma (HCC). HBV infection was confirmed by measuring hepatitis B surface antigen and HBV-DNA in the serum, and HCV infection was confirmed by measuring antibody to HCV using a 2nd generation test and HCV-RNA in serum. Some 54.0% of the patients had HCV infection only, 27.0% had HBV infection only, and 9.5% had both HCV and HBV infection. Only 9.5% of HCC patients had neither HCV nor HBV markers. These results indicate that, in Japan, HCV and HBV infection is an important factor associated with HCC, and that the hepatitis virus may have a role in the carcinogenesis of HCC.

[A case of multiple inthorathoracic neurilemmoma with cutaneous lesions]

A 33-year-old man with right inguinal mass was admitted to our hospital because of an abnormal shadow on his chest X-ray film. Surgery was performed. These tumors originating from the right 7th, 8th intercostal and right cutaneous femoralis nerve were removed. Histologically, excised tumors were diagnosed as neurilemmoma. There had been only 4 cases of inthorathoracic multiple neurilemmoma with skin lesion, in Japan. We reviewed and discussed the Japanese literature.

Atypical peritracheobronchial vasculitis and an effective treatment

We report an interesting case of vasculitis in which the inflammatory lesion was limited to the peritracheobronchus. This case showed positive antineutrophil cytoplasmic antibodies, diffuse peritracheobronchial swelling, and vasculitis in its histology. Steroid therapy was effective for both roentgenological and serological findings. Although the biopsy specimen shows only inflammation and does not satisfy the WHO criteria of Wegener's granulomatosis (WG), a possible diagnosis of WG should not be disregarded.

[Surgically successful treatment of pleural empyema with multiple bronchial fistulae--a case report]

A 62-year-old man who had undergone left lingual segmentectomy for pulmonary tuberculosis developed left chronic localized pleural empyema with multiple bronchial fistulae in the region of surgical gauze left in the thoracic cavity. We surgically removed the gauze and fenestrated the empyema. After disinfection of the region of suppuration, small fistulae which were less than 2 mm in diameter were closed by fibrin-glue-packing and consolidation of the orifices using 40% silver nitrate solution. Two and one-half months later a second operation was performed. Residual large fistulae were closed by fibrin-glue-packing and suturing of their orifices, and the empyema space was then obliterated by muscle flap plombage. The patient's postoperative course was good and the empyema was completely cured with this treatment.

Fibril formation in the rough endoplasmic reticulum of lymphoma cells. A case report with histopathologic, immunohistochemical, electron and immunoelectron microscopic studies

Signet ring cell lymphoma (SRCL) is a relatively new and infrequently described entity, characterized by an intracytoplasmic mass displacing the nucleus at the periphery. We present here a case of a Japanese female aged 73 with a retroperitoneal mass diagnosed as SRCL at autopsy. The neoplastic lymphoid cells showing signet ring appearance, due to the displacement of the nucleus to one side by intracytoplasmic eosinophilic inclusions, were immunoreactive for LCA, L26 and lambda light chains but PAS-negative. A small number of tumor cell nuclei demonstrated proliferating cell nuclear antigen-positive, but signet ring cells were negative. Ultrastructural study disclosed that fibrillary, lamellar or homogenous materials within rough endoplasmic reticulum of the tumor cells were selectively labeled by gold particles to anti-lambda antibody. A periodicity of 20-25 nm was observed in the fibrillary inclusions arranged haphazardly. The morphologic appearances of the case and the differential diagnosis are preceded by a review of the literature.

Pronounced enhancement of .NO-dependent antimicrobial action by an .NO-oxidizing agent, imidazolineoxyl N-oxide

The antimicrobial action of .NO against Cryptococcus neoformans was investigated by using imidazolineoxyl N-oxide, which we recently reported removes .NO via oxidation (T. Akaike, M. Yoshida, Y. Miyamoto, K. Sato, M. Kohno, K. Sasamoto, K. Miyazaki, S. Ueda, and H. Maeda, Biochemistry 32:827-832, 1993). No appreciable fungicidal activity was observed in neutral .NO solutions. Imidazolineoxyl N-oxide induced or enhanced fungicidal action in neutral or acidic .NO solutions, respectively. Our results provide convincing evidence that .NO is not a microbicidal molecular species.

Rigid spine syndrome and nocturnal alveolar hypoventilation

A 17-year-old Japanese woman with rigid spine syndrome (RSS) presented with respiratory failure leading to CO2 narcosis. The clinical symptoms were drowsiness, asterixis and cardiac arrhythmias. Tracheostomy and temporary ventilatory support abolished these symptoms. However, polygraphic sleep studies without a ventilator revealed Cheyne-Stokes respiration and profound arterial oxygen desaturation during rapid eye movement sleep. Nocturnal ventilatory support improved not only nocturnal hypoxemia, but daytime blood gas values during spontaneous breathing. These findings indicate that the onset of respiratory failure is preceded by severe nocturnal hypoxemia and that the evaluation and control of nocturnal respiratory insufficiency is essential for RSS patients.

[A case of Listeria rhombencephalitis with a secondary vasculitis suggested by MRI]

We reported a rare case of Listeria rhombencephalitis with meningitis. A 48-year-old healthy man suddenly experienced high fever and headache, then he had lower cranial nerve's palsies and mental dysfunction developed during one week period. On admission, his temperature was 38 degrees C. He was slightly delirious and euphoric. He had nuchal rigidity, mild paresthesia over his left cheek to left upper lip, a right sixth nerve palsy, dysphagia, hiccup, nasal voice and left cerebellar ataxia. His tongue deviated toward the right side on protrusion. A CSF culture grew Listeria monocytogenes. Intravenous antibiotic therapy (PIPC, minocycline hydrochloride) produced improvement in one month except for mild paresthesia and dysphagia. He almost recovered after 7 months of illness. Brain MRI on T2 weighted image demonstrated multiple small ischemic lesions in the left lateral medulla, upper pontine tegmentum in the right side, and pontine tegmentum in the left side. These lesions enhanced by Gd. were assumed to be due to the secondary vasculitis. Listeria rhombencephalitis is extremely rare in human beings. To our knowledge only thirteen cases have been reported. In seven cases, post-mortem pathological findings confirmed necrotizing angitis in brainstem. Clinical aspects of Listeria rhombencephalitis were discussed, and the entity of this disease should be considered as a treatable cause of acute progressive brainstem meningoencephalitis.

The epidemiology and infection route of asymptomatic HCV carriers detected through blood donations

The Japan Red Cross started screening donated blood for anti-HCV in Nov. 1989. Approximately 0.9% of donors were found to be positive by the 1st generation antibody test. The authors started a carrier clinic for the medical care of apparently healthy HCV carriers. Donors whose antibodies were strongly positive both by 1st EIA and 2nd PHA were informed, and were confirmed by RIBA 2 and RT-PCR. A total of 262 carriers (150 males and 112 females) with mean age of 46.8 +/- 11.2 yrs have visited the clinic. Of these carriers 149 were diagnosed to be asymptomatic clinically, biochemically and echographically. Eighty-seven carriers had received blood transfusions 22.7 +/- 10.9 yrs previously, while 106 had had acupuncture. Sixty had a family history of liver disease. Fifty-four had a history of heavy alcohol intake. Tattoos and/or iv drug abuse were found in 11, and nosocomial needle accidents in 4. HBV antibodies were found in 145 cases (55%). In conclusion, approximately 60% of HCV carriers found at the time of blood donation were apparently asymptomatic, suggesting the need of longer follow-up. Main routes of infection were estimated to be blood transfusion (33%), other parenteral exposure routes (6%), household (10% or less), and acupuncture (20% or less), considering duplication and priority.

Resistance to nitric oxide in Mycobacterium avium complex and its implication in pathogenesis

Susceptibility of three different strains of Mycobacterium avium complex (MAC), i.e., one strain of M. avium (Mino) and two strains of M. intracellulare (31F093T and KUMS 9007), to nitric oxide (NO) generated by rat alveolar macrophages (M phi) or NO generated chemically by acidification of NO2- was examined in vitro. We also investigated the effects of NO on phagocytosis and superoxide anion (O2-) generation by M phi. The intracellular growth of M. avium Mino was significantly suppressed by NO generated by gamma interferon (IFN-gamma)-stimulated M phi, whereas that of two strains of M. intracellulare (31F093T and KUMS 9007) was not. M. avium Mino was also more susceptible to NO generated chemically by acidification of NO2- than the two M. intracellulare strains. In L-arginine (1 mM)-containing medium, NO release from the M phi assessed by measuring NO2- increased as the concentration of IFN-gamma increased. The enhancing potential of IFN-gamma for NO release became more pronounced when M phi were infected with 31F093T, an NO-resistant strain. A large amount of NO generated by IFN-gamma-stimulated M phi suppressed both phagocytosis and O2- generation by the M phi, especially after infection of the M phi with strain 31F093T. These results indicate that the intracellular growth of MAC is not always inhibited by NO generated by immunologically activated M phi; rather, NO generation induced by infection with an NO-resistant MAC strain suppresses phagocytosis of the M phi, which may allow extracellular spreading of such NO-resistant mycobacteria. Therefore, the pathogenic potential of MAC may be partly attributed to its resistance to NO.

[A case report of combined aortic and mitral regurgitation associated with ankylosing spondylitis]

We reported a case of ankylosing spondylitis which successfully underwent aortic valve replacement for combined aortic and mitral regurgitation. A 42-year-old man was admitted with symptoms of shortness of breath and anginal pain. He was previously diagnosed ankylosing spondylitis by an orthopedician A grade III/VI to and fro murmur was audible at the left sternal border. Retrograde aortography revealed severe aortic regurgitation and mild mitral regurgitation. Cardiac catheterization showed moderately pulmonary hypertension and high pulmonary artery wedge pressure. He underwent aortic valve replacement with SJM prosthetic valve. His postoperative course was uneventful. In Japan, ankylosing spondylitis is rare disease, and cardiac lesions associated with these conditions is seldom met to us. The surgical problems and management of these lesions are discussed.

[Rhabdomyolysis associated with pseudohypoparathyroidism type Ib--a case report]

An 18-year-old Japanese female with pseudohypoparathyroidism (PHP) type Ib presented with rhabdomyolysis. The patient, who had been tired after long-distance hiking, experienced paresthesiae and subsequent muscle cramps of the four extremities after drinking a small quantity of alcohol. An occurrence of rhabdomyolysis was confirmed by marked elevation of serum CK activities and muscle necrosis revealed by both CT scanning and biopsy. The exertion and alcohol intake probably induced the initial muscle injury. Subsequently, the muscle necrosis might have worsened the asymptomatic hypocalcemia and decreased 1,25-(OH)2 vitamin D synthesis in PHP type Ib, which resulted in severe muscle cramps and further muscle destruction.

[Mechanisms of clearance of foreign bodies by macrophages]

Macrophages have specific functions related to the sites where they are found. Pulmonary alveolar macrophages (PAM) may play an important role the clearance of invading and degenerative substances from the alveolar spaces. To clarify the mechanisms of the clearance by macrophages, we studied the role of scavenger receptors (SR) and Fc receptors (FcR) of PAM. 1) SR: Expression and localization of SR in human PAM. Type I and II SRs were expressed in human PAM, and the two SRs were confirmed in the same cells by double staining method using polyclonal antibodies to the SRs. These SRs were localized on the cell membrane and the endosome in part. The expression of SR in PAM from normal nonsmokers, smokers and patients with pneumoconiosis was studied, but there were no differences among these groups. Kinetics of SR and acetylated low density lipoprotein (acLDL) in PAM. SR recognized acLDL, and SR and acLDL-Au conjugates were concentrated in a coated pit 2 min after incubation. The conjugates were then internalized in the endosome 5 min after incubation. A few acLDL-Au conjugates were present in the endosome near the nucleus, but most of them were found in the lysosome 10 min after incubation. SR was found in the Golgi apparatus 15 min after incubation. These results suggest that SR in PAM may play an important role in the removal of alveolar surfactant. 2) FcR: Effects of FcR mediated phagocytosis on O2-release and phagosome-lysosome fusion in the phagosome of PAM.(ABSTRACT TRUNCATED AT 250 WORDS)

[A case of progressive supranuclear palsy presenting mouth opening difficulty with tonic contraction of the orbicularis oris muscle]

A 72-year-old man developed supranuclear ophthalmoplegia, bradykinesia, rigidity, unsteady gait, dementia, dysphagia, retrocollis, grasp reflex and apraxia of eyelid opening. These findings were compatible with progressive supranuclear palsy (PSP). At the age of 66, he presented a peculiar phenomenon characterized by simultaneous tonic contraction of the orbicularis oris muscle (OOM) and the palatal muscles elicited by pronouncing "pa", which resulted in difficulty of voluntary opening of the mouth and the rhinopharynx. Therefore, the respiration air reciprocated between the lung and the closed mouth. The expiratory pressure puffed out the cheeks, while the lips remained tightly closed. While the respiratory movements and the pressure increased by degree, the OOM contracted more strongly in proportion to the pressure. Sixty to ninety seconds after the elicitation, the pressure overcame the contraction of the OOM and the course of the phenomenon was completed. The electromyograms showed that the OOM activity was prolonged after initial voluntary contraction, remaining thus after a tracheostomy for pneumonia at the age of 72, and that it increased in response to the pressure. Apraxia of eyelid opening, one of the other symptoms, resembled this phenomenon in terms of the aspect of difficulty of voluntary mouth opening. The "holding" phase of grasp reflex, yet another symptom, resembled it in the recruitment of the OOM activity. The phenomenon is not common in patients with PSP. However, we concluded that it may be included among the symptoms of PSP because it has similar characteristics to apraxia of eyelid opening and grasp reflex, which are not uncommon in patients with PSP.

Creutzfeldt-Jakob disease with congophilic kuru plaques: CT and pathological findings of the cerebral white matter

In a patient whose Creutzfeldt-Jakob disease with congophilic kuru plaques that was proved at necropsy, the early brain CT showed low-density areas in the cerebral white matter before cortical atrophy and ventricular enlargement became apparent. Subsequently, there occurred diffuse white matter lucency and severe brain atrophy. At necropsy, there was severe white matter destruction which was more prominent than cortical neuronal loss. Serial CT scans were of great value for demonstrating the early and predominant changes in the cerebral white matter.

[Isolated angiitis of the CNS associated with Hashimoto's disease]

In 1987, a 69-year-old female suffering from epilepsy and right hemiparesis was admitted to the hospital and given conservative therapy. During the next three weeks she became a stuporous state. Steroids were then prescribed, and she made a complete recovery. Following hormonal and immunological investigations, a diagnosis of Hashimoto's disease with hypothyroidism was made. Following her discharge, thyroxin and anticonvulsant treatments continued. On May 30, 1989, at the age of seventy-one, the patient was found lying unconscious at home, and taken to our hospital. She had signs of a confused state, and seizures of her right arm on admission. Cranial computed tomography (CT) revealed a low density area in the left parieto-occipital lobe, which was heterogeneously enhanced by contrast medium. Magnetic resonance imaging (MRI) showed a lesion of low signal intensity in T1-weighted images and high signal intensity in T2-weighted images, which was homogeneously enhanced by Gd DTPA. Cerebral angiography disclosed no abnormality. Two weeks later, follow-up CT showed that the lesion had become larger and markedly enhanced. A brain tumor, probably malignant lymphoma, was suspected. On June 14, stereotaxic biopsy of the enhanced lesion was performed. Histopathological examination disclosed dense infiltration of the entire walls of many small parenchymal vessels, both arterioles and venules, by lymphocytes. Treatment for angiitis (betamethasone 16 mg daily) was started on June 20, then gradually tapered, and the lesion diminished on CT. Our case has some features of both isolated angiitis of the central nervous system and encephalopathy in compensated Hashimoto's disease. It is suggested that some common base of the autoimmune diseases exists in this case.

[Intracellular killing mechanisms of alveolar macrophages against Mycobacterium avium complex]

To clarify the intracellular killing mechanisms of alveolar macrophages against Mycobacterium avium complex, effects of cytokines on O2- and NO2- production from normal and BCG-induced alveolar macrophages were studied. Intracellular growth of M. avium complex was inhibited in the alveolar macrophages stimulated by TNF, but not IFN. Enhancement of O2- production by normal alveolar macrophages stimulated by cytokines, was associated with the inhibition of intracellular growth of M. avium complex. However, when NO2- production by the alveolar macrophages was enhanced by the stimulating of IFN or IFN+TNF, in the presence L-arginine in the culture medium, their defense activity against M. avium complex decreased.

[An autopsy case of four primary cancers including malignant meningioma]

The authors describe an autopsy case of a 68-year-old man with four primary cancers diagnosed at autopsy including malignant meningioma, early esophageal cancer, early gastric cancer and lung cancer. Recently, the number of patients with four and five primary cancers has been increasing. According to the Annual of the Pathological Autopsy Cases in Japan, 156 cases were reported during 16 years from 1974 to 1989. In this series, cancers were detected most frequently in stomach, colon, lung, prostate, liver and esophagus. However, only two cases with four and five primary cancers including malignant meningioma were reported. Because occult cancers like prostatic cancers are unexpectedly diagnosed at autopsy, the incidence of four and five primary cancers including malignant meningioma seems to be higher when the central nervous system is examined more frequently at autopsy.

Changes in the plasma abnormal prothrombin level following treatment of hepatocellular carcinoma

The Hokkaido Liver Cancer Study Group focused on the changes in PIVKA-II levels observed in 61 HCC patients after several regimens of treatment in comparison with the AFP levels and the pathophysiological characteristics of HCC. The overall positivity rate for PIVKA-II was 47%, and there was no correlation between the PIVKA-II values and the AFP levels. Accordingly, the HCC detection rate was increased by about 20% by the measurement of both markers. In all, 13 patients underwent hepatic resection, and nonsurgical therapy was carried out in the other 48 subjects. Of the 6 surgically treated patients, 5 (83%) showed a fall in PIVKA-II levels to the normal range immediately after surgery, whereas 14/29 (48%) subjects receiving nonsurgical treatment showed a decrease in PIVKA-II values. Although inconsistency between these tumor markers was detected in four treated cases, we concluded that assay for both of these two parameters may expand their clinical utility for the diagnosis of HCC and monitoring of patients after treatment.

[Diffuse cerebrospinal gliomatosis. Case report]

A 65-year-old male was admitted with memory and gait disturbance. A computed tomography (CT) scan showed bilateral, diffuse, low-density areas with two round, slightly enhanced masses. T1-weighted magnetic resonance image revealed a low-intensity area in the left paraventricular region, which converted to increased signal intensity, extending to the right paraventricular region through the splenium, on T2-weighted images. The tumor was diagnosed as glioblastoma multiforme after needle biopsy and treated by irradiation and chemotherapy. Seven months after admission, a CT scan revealed subependymal infiltration of the tumor with spotty calcification. He died of respiratory complications 11 months after the onset of symptoms. The autopsy showed brain swelling with flattened gyri. Horizontal sections of the brain showed diffuse enlargement of the white matter and basal ganglia with scattered hemorrhage and necrosis. Microscopically, the lesion was far more extensive and diffuse than was suspected from gross examination. Wide glial tumor cell infiltration was observed in the cerebral hemispheres, basal ganglia, brainstem, cerebellum, and even the cervical spinal cord with minimum destruction of the pre-existing architecture. Calcification was found around the thrombosed vessels and necrotic lesions. The clinical diagnosis and histological features of gliomatosis cerebri are discussed with reference to reported cases.

Cerebral angio- and neuro-Behçet's syndrome: neuroradiological and pathological study of one case

Cerebral angio-Behçet's syndrome is extremely rare and pathological studies are scarce. We describe a 63-year-old man who developed left homonymous hemianopsia and hemiparesis 16 years after the onset of cardinal symptoms of Behçet's syndrome. CT, MRI and PET studies disclosed cerebral lesion with reduced neuronal metabolism in the right hemisphere, which was resolved by glucocorticoid therapy. Cerebral angiography showed no filling of the right Rolandic, anterior and posterior parietal and angular arteries. The postmortem study revealed: (a) occlusive panarteritis of some medium-sized pial branches of the right middle cerebral artery, considered as angio-Behçet's pathology, and small infarctions due to the vascular occlusion; (b) patchy or confluent demyelinated foci with perivascular lymphocytic infiltration in the bilateral brain basis, predominantly in the right retro- and sublenticular structures, being equivalent to neuro-Behçet's pathology. Cerebral angio- and neuro-Behçet's syndromes could have occurred and progressed concomitantly, which suggests a close relationship between the two subclassified processes.

A case of HBs antigen negative fulminant hepatitis with IgM antibody to hepatitis B core antigen persisting more than seven years

A 33-year old dentist developed fulminant hepatitis. At admission, a test for IgM antibody to hepatitis B core antigen (IgM anti-HBc) was positive, while tests for HBsAg and HBeAg were negative. He was cured of the disease, but in follow-up examinations from 1983 to 1990 IgM anti-HBc was continuously detected with radioimmunoassay while HBsAg and HBV-DNA were absent in the serum. However, HBcAg was found in a biopsied liver specimen and a small quantity of HBV-DNA was detectable by polymerase chain reaction assay. These observation suggest that the continuous detection of IgM anti-HBc without HBsAg in serum is due to persistent HBV infection and HBV replication in the liver.

Adenosine deaminase activity and free IL-2 receptor levels in serum from patients with mycoplasma pneumonia

Adenosine deaminase (ADA) activity and free interleukin (IL)-2 receptor levels were assayed in serum samples from patients with mycoplasma and bacterial pneumonia to evaluate the usefulness of these parameters in distinguishing between these diseases at an early stage. Serum ADA and free IL-2 receptor levels in patients with mycoplasma pneumonia (32.4 +/- 9.2 U/l, 960 +/- 204 U/ml) were significantly higher than those in patients with bacterial pneumonia (12.5 +/- 3.3 U/l, 425 +/- 86 U/ml) and in healthy controls (14.0 +/- 3.4 U/l, 286 +/- 49 U/ml) (p less than 0.001). Of the 20 mycoplasma pneumonia cases, 19 showed increased levels of ADA over 20.8 U/l; in 17 of the 19, the increase of ADA was seen before the elevation of the specific antibody to Mycoplasma pneumoniae. In contrast, serum ADA levels in all 20 cases of bacterial pneumonia were lower than 20.8 U/l. There results indicate that assays for serum ADA and free IL-2 receptor levels are useful in distinguishing between bacterial and mycoplasma pneumonia at an early stage.

Detection of IgM, IgA, and IgG antibodies to preS2 antigen in hepatitis B virus infection

Antibodies to the preS2 antigen (anti-preS2) of the hepatitis B virus (HBV), including IgA, IgM and IgG classes, were observed in patients with acute and persistent HBV infection. In acute HBV infection, rapid and marked serum IgM and IgA anti-preS2 responses were observed. Antibodies reached a peak of serum activity at about 1-2 months after the onset of clinical symptoms, and both antibodies disappeared from serum at 4 months after. IgG anti-preS2 was detected in the early phase of the illness, then the level of IgG anti-preS2 gradually rose during the recovery phase. In persistent HBV infection, IgG and IgM anti-preS2 were detected in sera where the preS2 antigen was present, and IgM anti-preS2 was significantly higher (p less than 0.05) in HBeAg-positive than in HBeAg-negative patients. These results indicate that an adequate humoral immune response to the preS2 antigen is induced during acute and persistent HBV infection.

Stimulus- and cumulative dose-dependent inhibition of O2- production by polymorphonuclear leukocytes of patients receiving corticosteroids

Since early in vivo studies in man have remained controversial as to the suppressive effects of glucocorticosteroids on the function of polymorphonuclear leukocytes (PMN), we tried to clarify those effects. The study population involved 19 inpatients on daily and prolonged corticosteroid therapy. Superoxide (O2-) production and chemotaxis were determined as a function of peripheral blood PMN, using various stimuli: concanavalin A (ConA) + cytochalasin D (CD), N-formyl-methionyl-leucyl-phenylalanine (FMLP) and phorbol myristate acetate (PMA), and the chemoattractants FMLP and zymosan activated serum (ZAS). In addition, the relationship between PMN function and corticosteroid dose was also evaluated. There was significant inhibition of PMN O2- production in the patients receiving corticosteroids depending on the stimulus (FMLP or PMA, 51% or 56% of controls; ConA + CD, not inhibited) but no significant inhibition of PMN chemotactic activity. Stimulation with FMLP showed an inverse relationship between O2- production and cumulative prednisolone dose (r = -0.41) in serial determination of O2- production in patients with a negative C-reactive protein (CRP) test. In the serial study of each patient with negative CRP we confirmed the suppression. These results suggest that O2- production by PMN could be inhibited, depending on the cumulative dose of corticosteroids in steroid-treated patients. This may be one possible mechanism of impaired host defences caused by corticosteroid therapy in man.

Triggering effects of opsonized-IgG antibody on the superoxide release in the phagosome and phagosome-lysosome fusion by pulmonary alveolar macrophages in rabbits

We studied the triggering effects of opsonized-IgG antibody on the superoxide (O2-) release and phagosome-lysosome fusion in the phagosome of pulmonary alveolar macrophages (PAM). Both were histochemically assayed in the same cell to enable simultaneous observation, using the qualitative superoxide dismutase (SOD)-inhibitable nitroblue tetrazolium (NBT) reduction test and the acridine orange (AO) method. When PAM from normal rabbit lungs were made to phagocytize the IgG-treated yeasts, the cells showed the enhanced release of O2- which acted directly on the antibody-coated yeasts as an oxidant, and the enhanced phagosome-lysosome fusion that was inhibited by SOD and was closely related to the enhanced release of O2- in the phagosomes. In contrast, neither enhanced O2- release nor phagosome-lysosome fusion was observed in the PAM which phagocytized saline-treated yeasts. These results may suggest that the opsonized-IgG antibody enhances the O2- release in the phagosome, resulting in the enhanced phagosome-lysosome fusion.

[An autopsy case of Neuro-Behçet's disease with the right middle cerebral artery occlusion on cerebral angiogram]

A case of Neuro-Behçet's disease with the right cerebral artery occlusion on cerebral angiogram was reported. A 63 years old man complained of headache and slight fever without exacerbations of ocular and mucocutaneous lesions, 16 years after he had suffered from recurrent oral aphthous ulcers, genital ulcers, uveitis and erythema nodosum. Laboratory examination demonstrated pleocytosis in the cerebrospinal fluid, a low density area with contrast enhancement in right temporal and parietal lobes in brain CT, a high signal intensity in the same area in T2-weighted image in brain MRI and the occlusion of the right middle cerebral artery on cerebral angiogram. After admission, left homonymous hemianopsia and hemiparesis appeared. With steroid therapy, these symptoms diminished and abnormal findings in brain CT and MRI disappeared, but psychiatric symptoms were exacerbated gradually. Finally he died of agranulocytosis and pneumonia. Neuropathologic findings showed panarteritis of branches of the right middle cerebral artery and infarction of its territories in addition to perivascular infiltrations and foci of demyelination which were prominent in the cerebral basal regions.

[A case of chronic inflammatory demyelinating polyradiculoneuropathy with nocturnal myoclonus]

A 43-year-old man began to notice progressive tingling sensation in his legs and unsteadiness in walking in 1983. His symptoms diminished with prednisolone treatment. In 1986, the same symptoms developed again and abated with prednisolone and plasmapheresis. In 1988 he was admitted because of progression of the symptoms in the legs. Neurological examinations showed mild muscle atrophy and weakness in the legs, loss of the deep reflexes, and impairment of cutaneous and deep sensation of the extremities. Heel-knee test was unsteady, and his gait was wide-based. In addition, Babinski and Chaddock signs were positive bilaterally. He had spontaneous myoclonic jerks of his legs, so-called "tonic triple flexion". These jerks were particularly evident during sleep, and were considered to be "nocturnal myoclonus". The same jerks were provoked by painful stimuli or Babinski's, Marie-Foix's maneuver. These jerks were considered to be so-called "spinal automatism" of spinal or brainstem origin. The latencies of VEP on both sides were prolonged and ABR showed abnormalities indicative of brainstem lesion. There were no abnormalities in cranial and spinal MRI. Our case was proven to have central nervus system lesions in addition to findings of chronic inflammatory demyelinating polyradiculoneuropathy.

Chronic progressive spinobulbar spasticity with disturbance of voluntary eyelid closure. Report of a case with special reference to MRI and electrophysiological findings

We describe a 56-year-old man who had a progressive pseudobulbar palsy, spastic tetraparesis, forced laughing and disturbance of voluntary eyelid closure, and was clinically compatible with chronic progressive spinobulbar spasticity. Magnetic resonance images (MRI) revealed atrophy of the bilateral motor cortices and single photon emission tomography after intravenous injection of N-isopropyl-p-iodoamphetamine iodine-123 (IMP-SPECT) showed hyporadioactivity in the same regions. Electrophysiological studies on supranuclear paralysis of eyelid closure demonstrated that so-called apraxia and motor impersistence coexisted and that in attempts to keep the eyelid closed the inhibition of basal activity of the levator palpebrae superioris muscle and activation of the orbicularis oculi muscle were insufficient, indicating the impaired reciprocity of these ocular muscles. The corresponding lesion of these eyelid symptoms was considered to be the bilateral motor cortices.

[Transient monocytic skin infiltrate during preleukemic phase of acute myelomonocytic leukemia]

An acute myelomonocytic leukemia presenting transient skin rash during preleukemic phase was described. Following four years of unexplained leukopenia, a generalized exanthema developed and subsequently regressed spontaneously. The skin biopsy and immunohistochemistry revealed monocytic infiltration into the dermis. Twenty-eight months later, the patient became leukemic and died. The skin lesions, however, did not occur after leukemic transformation. Probably transient monocytic skin infiltrate was a symptom of preleukemia, a stem cell neoplasm manifested by functionally abnormal maturation.

Identification of CSF fistulas by radionuclide counting

A radionuclide counting method, performed with the patient prone and the neck flexed, was used successfully to diagnose CSF rhinorrhea in two patients. A normal radionuclide ratio (radionuclide counts in pledget/radionuclide counts in 1-ml blood sample) was obtained in 11 normal control subjects. Significance was determined to be a ratio greater than 0.37. Use of radionuclide counting method of determining CSF rhinorrhea is recommended when other methods have failed to locate a site of leakage or when posttraumatic meningitis suggests subclinical CSF rhinorrhea.

[Primitive neuroectodermal tumor with peritoneal metastasis through a ventriculoperitoneal shunt. Case report]

A 13-month-old boy admitted with lethargy and hydrocephalus was found to have a right thalamic mass. Ventricular drainage was instituted, and the tumor mass was reduced by partial resection and local irradiation. A ventriculoperitoneal shunt was then placed. However, the tumor recurred 16 months later, with extensive ventricular seeding and peritoneal metastasis through the shunt tube. The child died 22 months after onset. Histological study of surgical specimens of the primary tumor and autopsy specimens of the brain and peritoneal metastatic tumors revealed poorly differentiated, small, round cells with numerous mitotic figures. In addition, autopsy specimens of the brain tumor contained areas of ependymal, oligodendroblastic, and spongioblastic differentiation. On immunohistochemical study, the tumor cells of each specimen were positive for anti-neuron specific enolase and anti-neurofilament antibodies, but negative for anti-glial fibrillary acidic protein antibodies. Electron microscopy revealed some zonulae adherens. These findings strongly suggest that the tumor originated from primitive multipotential cells capable of differentiating into ependymal, glial, and neuronal lines.

[A case of pulmonary alveolar proteinosis accompanied with the elevation of CEA (carcinoembryonic antigen) in bronchoalveolar lavage fluid]

A 44-year-old man was admitted with increasing dyspnea and butterfly shadow on his chest roentgenogram. Both the bronchoalveolar lavage and transbronchial lung biopsy (TBLB) led to a diagnosis of pulmonary alveolar proteinosis. CEA level in his bronchoalveolar lavage fluid (BALF) (216.8 ng/ml) was markedly elevated more than that in his serum (50.6 ng/ml). The localization of CEA on TBLB specimen stained by peroxidase-antiperoxidase technique using anti-CEA antibody was investigated and it was found that some alveolar epithelial cells and the material filling the alveoli were positively stained. Functions of alveolar macrophages in BALF were also studied, that is, adherence to glass, cell spreading, the nitroblue tetrazolium reduction, phagocytosis of immunobeads, and the activity of lysosomal enzymes, and found that all of those functions were lower than that of normal smokers. It was suggested that type II alveolar epithelial cells were those which produced and secreted CEA into the alveoli, as they do surfactant-like material in pulmonary alveolar proteinosis, and that the dysfunction of alveolar macrophages was secondary to the overingestion of the proteinaceous material in the alveoli.

[Clinical evaluation of PIVKA-II as a marker of hepatocellular carcinoma]

PIVKA-II (protein induced vitamin K absence or antagonist-II) levels in plasma were measured using ELISA in patients with hepatocellular carcinoma (HCC). PIVKA-II was detected in 53 of 97 patients (54.6%) of HCC, and the combination assay of PIVKA-II and AFP identified 69 of 97 patients (71.1%) with HCC. However, the positive rate of PIVKA-II (6.1%) was lower than that of AFP (37.5%) in patients with HCC less than 2 cm in diameter. The concentration of PIVKA-II was markedly reduced within 2 weeks after treatment in patients with HCC showing a favorable response to Lp-TAE or Lp-TAI. Although PIVKA-II is a valuable marker for the diagnosis and follow-up of patients with HCC, it must be noted that the change to negative concentration of PIVKA-II after treatment does not mean complete necrosis of the tumor.

[Usefulness of serum adenosine deaminase activity in the early diagnosis of Mycoplasma pneumonia]

It is sometimes difficult to clinically diagnose mycoplasma pneumonia at an early stage before the rise of titer of antibody to Mycoplasma pneumoniae. Mycoplasma pneumonia may be related with T-lymphocyte activity, and its inflammatory process is different from that of bacterial pneumonia. Adenosine deaminase (ADA) activity is a predominant T-lymphocyte enzyme, and its plasma activity is high in diseases in which cellular immunity is stimulated. In this study, we have investigated 31 cases with pneumonia (11 cases of mycoplasma pneumonia and 20 cases of bacterial pneumonia) within 10 days after onset to evaluate the usefulness of ADA measurement in the diagnosis of mycoplasma pneumonia. Serum ADA activity in the group of mycoplasma pneumonia was 32.1 +/- 12.0 U/l (63.9-18.8 U/l), that of non-mycoplasma pneumonia 12.5 +/- 3.3 (4.6-18.6) U/l, and that of normal control 14.0 +/- 3.4 (6.3-19.3) U/l. ADA activity of the group of mycoplasma pneumonia was significantly higher than those of non-mycoplasma pneumonia and normal control (p less than 0.001). This results suggest that serum ADA activity in patients with acute pneumonia may be useful for the early diagnosis of mycoplasma pneumonia.

Cooperative study on arterial regional chemotherapy for primary liver cancer in Hokkaido

The Liver Study Group of Hokkaido analyzed a total of 57 patients with non-resectable primary liver cancers, which were treated by intra-arterial adriamycin infusion chemotherapy combined with lipiodol and/or the Gelform embolization of the hepatic arteries. Of the ten patients considered clinical responders, three complete response patients and seven partial response cases were obtained. The overall response rate was 17.5%. The median survival period at each clinical stage was as follows: stage I: 13.0 months, stage II: 16.0 months, stage III: 11.5 months and stage IV: 4.7 months. The common side-effects of this treatment were nausea, vomiting and anorexia. Hematological toxicities were also found, but there was no patient who suffered from severe complications.