Idiopathic unilateral adrenal hemorrhage in an elderly patient

We report the case of an 85-year-old woman who has been undergoing treatment for hypertension but has not received anticoagulation therapy. The patient was admitted to our hospital for the evaluation of a right adrenal tumor (size, 10 × 9 cm²). Preoperative contrast-enhanced computed tomography and magnetic resonance imaging findings were indicative of adrenal hemorrhage (AH). Laboratory data revealed mild anemia but no adrenal dysfunction. The final pathological diagnosis was simply idiopathic adrenal hematoma. There is no case report of exactly idiopathic AH over 80 years old. We report an unusual case of idiopathic unilateral adrenal hematoma in an elderly patient. It is important to distinguish this benign lesion from a neoplasm and to consider idiopathic AH in an adrenal tumor during differential diagnosis in elderly patients who have not received anticoagulation therapy or suffered from trauma.

Scavenger receptor class BI mediates the anti-apoptotic effect of erythropoietin

A scavenger receptor of the B class (SR-BI)/human homolog of SR-BI, CD36, and LIMP II analogous-1 (CLA-1), has been identified as a receptor for high-density lipoprotein (HDL). Mice lacking SR-B1 develop anemia, plausibly explained by the observation that the erythrocyte life-span in these animals is reduced. Erythropoietin (EPO) is known to promote survival of erythroid cells, in large part through protection from apoptosis. We have examined the role of EPO on hSR-BI/CLA-1 expression and erythrocyte apoptosis. Endogenous expression of hSR-BI/CLA-1 was increased by exposure to EPO. EPO increased transcriptional activity of hSR-BI/CLA-1 promoter. The stimulatory effect of EPO on hSR-BI/CLA-1 promoter activity was abrogated by LY294002, specific inhibitor of phosphatidylinositol-3 kinase (PI3K). Constitutively active Akt stimulates the activity of the hSR-BI/CLA-1 promoter and a dominant-negative mutant of Akt abolished the ability of EPO to stimulate promoter activity. Finally, EPO in combination with HDL protected the cell from apoptosis, which suggests that hSR-BI/CLA-1 induced by EPO might contribute to the erythrocyte life-span.

Emphysematous cystitis with diabetic neurogenic bladder

A 62-year-old diabetic woman suffering from high fever was admitted to our hospital. She had a lower abdominal phantom tumor and hyperglycemia. The results of urine analysis showed hematuria and bacteriuria. X-ray and computed tomography revealed gas accumulation in the wall of the bladder. Escherichia coli was identified in urine culture. On the basis of the lack of urine output and the identification of residual urine on catheterization, a diagnosis of emphysematous cystitis with diabetic neurogenic bladder was established. The patient recovered after discontinuation of urinary drainage, intensive insulin therapy, and antibiotic therapy.

Detection of increased arterial stiffness in a patient with early stage of large vessel vasculitis by measuring cardio-ankle vascular index

Large vessel vasculitis leads to arterial wall thickening and stiffening because of chronic inflammatory changes. The cardio-ankle vascular index (CAVI) is recently utilized for assessing arterial stiffening caused by atherosclerosis-related diseases, including hypertension and diabetes, as well as aging. CAVI is mathematically calculated from stiffness index beta, which is established as a parameter of arterial stiffness independent of blood pressure. However, there are no data regarding arterial stiffness assessed by CAVI for large vessel vasculitis. We describe a patient with large vessel vasculitis who showed aortic wall thickening and increased CAVI without hypertension. A 68-year-old woman presented at our hospital with recurrent fever of 2-month duration, fatigue, neck pain, and weight loss. The images of 18F-fluorodeoxyglucose-positron emission tomography (18F-FDG-PET) demonstrated significant 18FDG uptake (indicating increased metabolic activity and presence of inflammation) in the aorta and its major branches, including the carotid and subclavian arteries. Contrast-enhanced magnetic resonance imaging demonstrated wall thickening of the thoracic aorta. These imaging findings resulted in the diagnosis of large vessel vasculitis. The patient showed normal brachial blood pressure (right, 122/72 and left, 121/66 mmHg). However, CAVIs on both sides (right, 10.3 and left, 10.4) were elevated (normal value for her age, 9.1 +/- 0.8). In conclusion, arterial stiffness in patients with large vessel vasculitis may be increased because of the arterial wall thickening and inflammatory changes. Thus, CAVI may be promising for detection of increased arterial stiffness in patients with large vessel vasculitis in the early stage, in which blood pressure is normal.

Systemic candesartan reduces brain angiotensin II via downregulation of brain renin-angiotensin system

The renin-angiotensin system has an important function in the regulation of blood pressure as well as in pathophysiological processes in the central nervous system. We examined the effects of the angiotensin receptor blocker candesartan (10 mg kg(-1) per day, p.o.) on brain angiotensin II levels in angiotensin II-infused hypertensive rats. Angiotensin II or vehicle was infused subcutaneously for 14 days in Sprague-Dawley rats. Angiotensin II infusion resulted in increased blood pressure, an effect that was blocked by candesartan treatment. There was no effect of the angiotensin II infusion on Angiotensin II levels in the brain or on blood-brain barrier permeability. Brain tissue angiotensinogen and angiotensin converting enzyme mRNA levels were not changed by angiotensin II infusion but were decreased by candesartan treatment. At 2 weeks of treatment, CV11974, an active form of candesartan, was detectable in the plasma but was not detectable in brain tissue. These data suggest that treatment with candesartan decreases brain angiotensin II by decreasing brain angiotensinogen and angiotensin converting enzyme gene expression.

Inhibition of cytochrome c release by 10-N-nonyl acridine orange, a cardiolipin-specific dye, during myocardial ischemia-reperfusion in the rat

The release of cytochrome c from the mitochondria to the cytosol is a critical step for downstream caspase-mediated apoptotic signal transduction in ischemia-reperfusion (I/R)-induced myocardial tissue injury. 10-N-nonyl acridine orange (NAO), a cardiolipin-specific dye, has been shown to inhibit Bid-mediated cytochrome c release from isolated mitochondria in vitro; however, the possible protective effects of NAO and the mechanisms underlying the protection from myocardial I/R-induced tissue injury in a rat model are unknown. Male Sprague-Dawley rats were subjected to a 30-min coronary arterial occlusion followed by reperfusion. All rats received either vehicle or NAO (100 microg/kg iv) 10 min before the occlusion. The infarct size in the heart at 24 h after reperfusion was significantly reduced in NAO-treated rats compared with vehicle-treated rats. NAO treatment significantly reduced the cytosolic cytochrome c contents and caspase-9 activity in the ischemic region but did not affect caspase-8 activity. Furthermore, NAO treatment markedly suppressed the translocation of truncated Bid, a proapoptotic Bcl-2 family member, to the mitochondrial fraction. NAO also suppressed the mitochondrial swelling and oxygen uptake stimulated by calcium overload. The results suggest that NAO possesses protective effects against myocardial I/R injury, which may be due to the suppression of cytochrome c release through blockade of truncated Bid translocation to mitochondria and inhibition of the opening of mitochondrial permeability transition pores.

Exendin-4 regulates pancreatic ABCA1 transcription via CaMKK/CaMKIV pathway

ATP-binding cassette transporter A1 (ABCA1) in pancreatic β cells influences insulin secretion and glucose homeostasis. This study investigates whether the long-acting agonist of the glucagon-like peptide 1, namely exendin-4, which mediates stimulatory effects on ABCA1 gene expression, could interfere with the Ca²⁺/calmodulin (CaM)-dependent protein kinase (CaMK) cascade. ABCA1 promoter activity was examined by reporter gene assay in rat insulin-secreting INS-1 cells incubated with exendin-4. CaMKIV activity was assessed by detection of activation-loop phosphorylation (Thr¹⁹⁶) of CaMKIV. We investigated the influence of the constitutively active form (CaMKIVc) or CaMKIV knockdown on ABCA1 expression. Increased abundance of ABCA1 protein was noted in response to rising concentrations of exendin-4 with maximum induction at 10 nM. Exendin-4 also stimulated ABCA1 promoter activity, but failed to do so in the presence of STO-609, a CaMKK inhibitor. Up-regulation of CaMKIV phosphorylation (at Thr¹⁹⁶) peaked after 10 min. of exposure to exendin-4. CaMKIVc enhanced or up-regulated ABCA1 promoter activity in INS-1 cells. Furthermore, exendin-4 induction of ABCA1 protein expression was significantly suppressed in cells treated with CaMKIV-siRNA. Activation of the CaMKK/CaMKIV cascade by exendin-4 stimulated ABCA1 gene transcription, indicating that exendin-4 plays an important role in insulin secretion and cholesterol ester content in pancreatic β cells.

Ectopic mediastinal parathyroid adenoma: a cause of acute pancreatitis

A 38-year-old male was admitted to our hospital with epigastric pain, and he was confirmed to have acute exudative pancreatitis. After the episode of acute pancreatitis subsided, laboratory investigation revealed increased serum calcium (12.0 mg/dl), decreased serum phosphorus (2.7 mg/dl), and increased serum parathyroid hormone (intact) levels (131 pg/ml). A computed tomography (CT) scan of the neck did not reveal any mass lesions in the parathyroid gland. However, (99m)Tc sestamibi scintigraphy revealed that there was one functioning parathyroid gland in the upper mediastinum. Combined (99m)Tc sestamibi scintigraphy and CT scan confirmed the diagnosis of primary hyperparathyroidism in the mediastinum. Microscopic examination revealed the presence of a parathyroid adenoma (1.3 x 0.4 cm(2)) adjacent to the atrophic parathyroid gland in right thymus gland. We report the case of a patient diagnosed with primary hyperparathyroidism due to an ectopic mediastinal parathyroid adenoma. An ectopic mediastinal parathyroid adenoma may manifest as an episode of acute pancreatitis. Preoperative investigation to determine the exact location of an adenoma should include two types of imaging studies, preferably (99m)Tc sestamibi scintigraphy and CT of the neck and chest.

Exendin-4 regulates glucokinase expression by CaMKK/CaMKIV pathway in pancreatic beta-cell line

AIM

Glucokinase (GK) in pancreatic beta cells is thought to be involved in insulin secretion and glucose homeostasis. This study investigates whether the long-acting agonist of the glucagon-like peptide 1, namely exendin-4, mediates stimulatory effects on GK gene expression through the Ca(2+)/calmodulin (CaM)-dependent protein kinase (CaMK) cascade.

METHODS

GK expression was examined by real-time PCR, western blot analysis and reporter gene assay in rat insulin-secreting INS-1 cells incubated with exendin-4. CaMKIV activity was assessed by detection of activation loop phosphorylation (Thr(196)) of CaMKIV. We investigated the effect of the constitutively active form (CaMKIVc) of CaMKIV on GK promoter activity.

RESULTS

Increased expression level of GK protein was noted in response to rising concentrations of exendin-4 with maximum induction at 10 nM. Real-time PCR analysis showed a significant increase in the amount of GK mRNA in response to rising concentrations of exendin-4. Exendin-4 also stimulated GK promoter activity but failed to do so in the presence of STO-609, a CaMKK inhibitor. This result is consistent with the observations that the upregulation of CaMKIV phosphorylation (at Thr(196)) peaked after 15 min of exposure to exendin-4 and that CaMKIVc enhanced or upregulated GK promoter activity in INS-1 cells. Furthermore, STO-609 significantly suppressed the exendin-4 - upregulated the expression of the GK protein.

CONCLUSION

Activation of the CaMKK/CaMKIV cascade might be required for exendin-4-induced GK gene transcription, indicating that exendin-4 plays an important role in insulin secretion in pancreatic beta cells.

Early detection of hypertension in a patient treated with sunitinib by measuring cardio-ankle vascular index

Cardio-ankle vascular index (CAVI) has been established as a marker of arterial stiffness, which is increased in hypertensive patients. CAVI reflects the stiffness of the aorta, femoral artery, and tibial artery. Sunitinib, multi-targeted tyrosine kinase inhibitor with both anti-angiogenic and anti-tumor activities, has been proved effective in patients with gastrointestinal stromal tumors. However, the treatment with sunitinib is often complicated by side effects such as hypertension. We describe an 84-year-old woman with gastrointestinal stromal tumor, who showed changes in arterial stiffness preceding the appearance of hypertension in the early phase after sunitinib initiation. The patient received sunitinib (50 mg given daily) for gastrointestinal stromal tumor. We assessed the influence of sunitinib on arterial stiffness every 7 days by measuring CAVI. The CAVI, which reflects arterial stiffness, was increased from 9.95 at baseline to 11.65 at 7 days after the initiation of sunitinib, whereas the blood pressure remained unchanged (117/72 and 119/76 mmHg). At 14 days after sunitinib initiation, the blood pressure was increased to 159/89 mmHg, indicating the occurrence of hypertension, while the CAVI was 11.90, the similar level detected at 7 days. Subsequently, sunitinib treatment was discontinued, because of the marked decrease in blood platelets. Both blood pressure and CAVI, together with blood platelets, were restored to the baseline values at 12 days after cessation of sunitinib. In conclusion, the increase in the CAVI preceded the appearance of sunitinib-induced hypertension. Arterial stiffness assessed by CAVI may be useful for early detection of sunitinib-induced hypertension.

Co-existence of glucagonoma with recurrent insulinoma in a patient with multiple endocrine neoplasia-type 1 (MEN-1)

Multiple endocrine neoplasia type 1 (MEN1) is an autosomal dominant disorder characterized by tumors of the parathyroid glands, the anterior pituitary, and the endocrine pancreas. Our patient was a 58-year-old man who manifested typical features of MEN-1 including primary hyperparathyroidism, lung carcinoid, and lipomas and insulinoma. He was admitted to our hospital because of recurrent hypoglycemia and a growth of pancreatic tumors. The first operation for insulinoma was performed when he was 20 years old. We found a germline mutation of the MEN1 gene (E45G, exon 2) in this patient. According to these examinations and his clinical course, the patient was diagnosed as having a recurrence of insulinoma. He subsequently underwent surgery for the pancreatic tumors. The majority of these tumor cells were immunohistochemically positive for insulin and negative for glucagon. A few nodules showed immunohistochemical staining positivity for glucagon but they were negative for insulin. Although it is uncommon for patients with MEN1 to exhibit insulinoma and glucagonoma, this case suggests the need for careful analysis of pancreatic tumors in patients with MEN1.

Tissue Doppler echocardiography for predicting arterial stiffness assessed by cardio-ankle vascular index

It has been reported that left ventricular (LV) diastolic functional parameters assessed by conventional Doppler echocardiography, which measures blood flow velocities in cardiac cavity, correlate with arterial stiffness assessed by the cardio-ankle vascular index (CAVI) and are markers for increased risk of cardiovascular events. Recently, tissue Doppler echocardiography, which measures velocities of regional cardiac wall, has been widely used for assessment of LV diastolic function because of more accuracy than conventional Doppler echocardiography. However, there are no data regarding the ability of tissue Doppler echocardiography for predicting increased arterial stiffness. We investigated the correlation of LV diastolic functional parameters from tissue Doppler echocardiography to CAVI in order to clarify the ability of tissue Doppler echocardiography for predicting increased arterial stiffness in patients with cardiovascular risk factors. Enrolled in the study were 70 patients (69 +/- 8 years) who had no overt heart disease, but had at least one of hypertension, diabetes, and dyslipidemia. The peak early diastolic mitral annular velocity (E') was measured as an index of LV diastolic function using tissue Doppler echocardiography. The E' was correlated with CAVI (r = -0.518, p < 0.001). The optimal cut-off point for the detection of abnormal CAVI (> or = 8.81) was 5.6 cm/s for E' (sensitivity 71%, specificity 71%). The decrease in E' correlated with both LV diastolic dysfunction and increased arterial stiffness. Therefore, the LV diastolic dysfunction assessed by tissue Doppler echocardiography may be useful for predicting increased arterial stiffness and cardiovascular events in the patients with risk factors.

c-Jun N-terminal kinases inhibitor suppresses the TNF-alpha induced MCP-1 expression in human umbilical vein endothelial cells

Monocyte chemoattractant protein-1 (MCP-1) is a 76-amino-acid chemokine that is considered to be an important chemotactic factor for monocytes. MCP-1 is expressed in the macrophage-rich areas of atherosclerotic lesions. A recent report indicated that MCP-1 expression in human umbilical vein endothelial cells (HUVECs) is induced by the stimulation of tumor necrosis factor (TNF)-alpha via the c-Jun N-terminal kinases (JNK) pathway. In this study, we examined the effects of JNK inhibitor (JNKI-1), on MCP-1 expression. The results of this study indicated that the expression of MCP-1 mRNA and protein were stimulated in the presence of TNF-alpha. TNF-alpha stimulated the phosphrylation of JNK, however, JNKI-1 inhibited the TNF-alpha stimulated MCP-1 secretion and gene expression. As expected, JNKI-1 blocked the stimulatory effect of TNF-alpha on the MCP-1 promoter activity. In conclusion, JNKI-1 partially inhibits the TNF-alpha-induced MCP-1 expression in HUVECs, and therefore JNKI-1 may be of therapeutic value in the treatment of diseases such as atherosclerosis.

Human scavenger receptor class B type 1 is regulated by activators of peroxisome proliferators-activated receptor-gamma in hepatocytes

High-density lipoprotein (HDL) particles play a critical role in cholesterol metabolism. The hepatic scavenger receptor class B type I (SR-B1) binds HDL particles for mediating reverse cholesterol transport (RCT), thus lowering the risk of atherosclerosis. Thiazolidinediones (TZDs), known to have potent enhancing effects on insulin sensitivity, have been developed for the treatment of non-insulin-dependent diabetes mellitus. They are a high-affinity ligand for the peroxisome proliferator-activated receptor gamma (PPAR-gamma), which belongs to a nuclear receptor superfamily. In this study, we examined the effects of thiazolidinedione PPAR-gamma on hepatic SR-B1 gene expression in human hepatoma G2 cell-line (HepG2). Results showed that hepatic SR-B1 mRNA and protein were increased on exposure to thiazolidinediones. Transcriptional activity of human SR-B1 (hSR-B1) gene paralleled the endogenous expression of the gene and was dependent on the dose of thiazolidinediones. We investigated the influence on the promoter activity of vector expressing PPAR and retinoid X receptor (RXR), cotransfected into the HepG2 cells along with SR-B1 promoter-reporter gene constructs. PPAR-gamma and RXR sufficiently induced the SR-B1 promoter activity in the HepG2 cells. Chromatin immunoprecipitation (ChIP) assay confirmed the binding of the PPAR-gamma to the SR-B1 promoter region. The mutagenesis of this binding site abolished the ability of the thiazolidinediones or PPARs to stimulate promoter activity. Together, these results indicate that the stimulation of SR-B1 expression in the liver is mediated in part by activation of the PPAR-gamma and RXR, and raise the possibility that this stimulation using thiazolidinediones conditions provides a protective mechanism for accelerated atherosclerosis in diabetes mellitus.

A case of Dunnigan-type familial partial lipodystrophy (FPLD) due to lamin A/C (LMNA) mutations complicated by end-stage renal disease

Dunnigan-type familial partial lipodystrophy (FPLD) is a rare monogenic adipose tissue disorder in which the affected subjects have increased predisposition to insulin resistance and related metabolic complications, such as glucose intolerance, diabetes, dyslipidemia, and hepatic steatosis. Our patient was a 35-year-old female who had been receiving insulin injection therapy for diabetes mellitus and was transferred to our hospital. She was diagnosed with FPLD on the basis of the following symptoms: increase in subcutaneous fat in the face, neck, and upper trunk; loss of subcutaneous fat in the lower limbs and the gluteal region. We found a heterozygous CGG to CAG transition in codon 482 of exon 8 in the gene encoding lamin A/C (LMNA), which leads to an arginine to glutamine substitution (R482Q). At the time of admission, her serum creatinine level was 8.4 mg/dl, and her blood urea nitrogen (BUN) level was 81 mg/dl. Her serum creatinine level was elevated and hemodialysis was performed twice every week. However, she died of cerebral hemorrhage 9 months after hemodialysis. Although it is uncommon for patients with FPLD to exhibit renal dysfunction and require hemodialysis, this case suggests the need for careful analysis of renal function in a patient with FPLD.

A case of non-Hodgkin's lymphoma primary arising in both adrenal glands associated with adrenal failure

It is known that adrenal insufficiency is one of the complications in primary adrenal lymphoma, especially those with bilateral adrenal involvement. A 73-year-old man was referred for general fatigue and high fever to the nearest hospital. The patient was transferred to our hospital for evaluation of bilateral adrenal tumors and hyponatremia. He was diagnosed as having non-Hodgkin's lymphoma (NHL) with primaries arising in both adrenal glands. Primary adrenal lymphoma (PAL) is a rare extra-nodal NHL. Although an appropriate treatment of this disease has not been established, our case has demonstrated that the combination of rituximab and THP-COP chemotherapy could be administered, and that it improved clinical manifestations. This case raises the suggestion that malignant lymphoma should be suspected in patients with bilateral adrenal tumors that present with progressive adrenal insufficiency.

Improvement in renal dysfunction and symptoms after laparoscopic adrenalectomy in a patient with pheochromocytoma complicated by renal dysfunction

A 70-year-old patient who was undergoing treatment for diabetes mellitus and chronic hepatitis was admitted to our hospital for evaluation of a tumor in the left adrenal gland (50 x 45 mm) and renal failure. On the basis of the patient's increased serum concentrations of catecholamines and other metabolites and the results of positron emission tomography (PET), the patient was diagnosed with a pheochromocytoma; iodinated metaiodobenzylguanidine ([(131)I]MIBG) scintigraphy was insufficient to establish this diagnosis. Subsequently, he underwent surgery for tumor resection. Histological examination suggested the tumor to be a malignant pheochromocytoma. After left adrenalectomy was performed, the elevated catecholamine and metabolite concentrations and the blood pressure were restored to normal, and the patient's symptoms of severe headaches and vertigo reduced. Furthermore, his renal function improved (Cr 2.0-1.2 mg/dl). Our patient exhibited a rare condition of pheochromocytoma complicated by renal failure, which was successfully treated with laparoscopic surgery.

Plasma brain natriuretic peptide as a surrogate marker for cardioembolic stroke

Background

Cardioembolic stroke generally results in more severe disability, since it typically has a larger ischemic area than the other types of ischemic stroke. However, it is difficult to differentiate cardioembolic stroke from non-cardioembolic stroke (atherothrombotic stroke and lacunar stroke). In this study, we evaluated the levels of plasma brain natriuretic peptide in acute ischemic stroke patients with cardioembolic stroke or non-cardioembolic stroke, and assessed the prediction factors of plasma brain natriuretic peptide and whether we could differentiate between stroke subtypes on the basis of plasma brain natriuretic peptide concentrations in addition to patient's clinical variables.

Methods

Our patient cohort consisted of 131 consecutive patients with acute cerebral infarction who were admitted to Kagawa University School of Medicine Hospital from January 1, 2005 to December 31, 2007. The mean age of patients (43 females, 88 males) was 69.6 ± 10.1 years. Sixty-two patients had cardioembolic stroke; the remaining 69 patients had non-cardioembolic stroke (including atherothrombotic stroke, lacunar stroke, or the other). Clinical variables and the plasma brain natriuretic peptide were evaluated in all patients.

Results

Plasma brain natriuretic peptide was linearly associated with atrial fibrillation, heart failure, chronic renal failure, and left atrial diameter, independently (F_4,126 = 27.6, p < 0.0001; adjusted R² = 0.45). Furthermore, atrial fibrillation, mitral regurgitation, plasma brain natriuretic peptide (> 77 pg/ml), and left atrial diameter (> 36 mm) were statistically significant independent predictors of cardioembolic stroke in the multivariable setting (Χ² = 127.5, p < 0.001).

Conclusion

It was suggested that cardioembolic stroke was strongly predicted with atrial fibrillation and plasma brain natriuretic peptide. Plasma brain natriuretic peptide can be a surrogate marker for cardioembolic stroke.