Eosinophilic myocarditis associated with toxicodermia caused by phenobarbital

We report on a 37-year-old man with congestive heart failure caused by eosinophilic myocarditis associated with toxicodermia. He developed many annular skin eruptions and peripheral eosinophilia due to reactions against phenobarbital. Right ventricular endomyocardial biopsy revealed extensive infiltration of eosinophils in the myocardium. A drug lymphocyte-stimulating test (DLST) for phenobarbital was positive. His symptoms, cardiomegaly, and cardiac function were improved by discontinuing phenobarbital followed by oral administration of prednisolone. We conclude that this eosinophilic myocarditis must have been induced by an allergic reaction to phenobarbital and that long-term eosinophilia contributed to the myocardial injury.

[Reasonable lymph node dissection for T2 or T3 midthoracic esophageal cancer with cervical lymph-node metastasis]

In order to determine the reasonable lymph node dissection for T2 or T3 midthoracic esophageal cancer with cervical lymph node metastasis, a retrospective study was carried out on 106 patients receiving resection between 1983 and 1996. Metastasis to cervical lymph node was obtained in 27.4% (29/106) of patients with T2 or T3 midthoracic esophageal cancer. Within 29 patients, metastasis in cervical node only, in two fields and in three fields occupied 17.2%, 41.4% and 41.4%, respectively. And according to the histologic examination of dissected lymph nodes, metastatic sites spreaded from neck to perigastric region. Five-year survival rate of 23 patients receiving curative operation was 33.0%, and that of 13 patients excluding 3-field metastasis was 51.9%. But the main sites of nodal recurrence were cervical or superior mediastinal nodes along the bilateral recurrent laryngeal nerves, and the rate of nodal recurrence was 47.8%. These results of actual state of lymph node metastasis and prognostic benefit of aggressive dissection suggest that 3-field lymph node dissection is mandatory for T2 or T3 midthoracic esophageal cancer with cervical lymph node metastasis. And we should endeavor to upgrade the precise dissection in order to decrease the nodal recurrence.

[Changes in the electroretinogram of eyes with diabetic retinopathy treated by vitrectomy]

Flash electroretinogram (ERG) and 30 Hz flicker ERG before and after operation were tested in 55 eyes of 46 patients with proliferative diabetic retinopathy who were treated by vitrectomy. The results were evaluated with preoperative ocular findings -the existence of retinal detachment, posterior vitreous detachment, panretinal photocoagulation (PRP) and vitreal hemorrhage and intraocular tamponade materials. In the group without retinal detachment, the amplitude of the ERG b-wave and a-wave after vitrectomy decreased significantly if PRP was not done before operation. In the group with retinal detachment, when retinal detachment was restricted to the posterior pole of the fundus, when posterior vitreous detachment had occurred in only a small area of the fundus, when there was vitreous hemorrhage or when silicone oil was injected in the operation, the amplitude of the ERG b-wave and a-wave decreased significantly after the operation. In both groups, the latency of 30 Hz flicker ERG was shortened significantly after vitrectomy.

Ultrasound biomicroscopic view of detachment of the ciliary epithelium in retinal detachment with atopic dermatitis

PURPOSE

The authors evaluated the effectiveness of ultrasound biomicroscopy to determine the condition of the ciliary body during perioperative examinations of patients with atopic dermatitis and retinal detachment.

METHODS

The authors compared two groups of patients with atopic dermatitis and retinal detachment. Parameters included patient age, gender, eye, cataract, type and location of breaks, macular involvement, detachment of the ciliary epithelium, and preoperative and postoperative best-corrected visual acuities. Group 1 included six patients (nine eyes) who were examined before surgery and after surgery using ultrasound biomicroscopy, with which the authors also measured the maximum height of the detachment of the ciliary epithelium. Group 2 included 10 patients (13 eyes) who did not undergo ultrasound biomicroscopy.

RESULTS

In group 1, ultrasound biomicroscopy showed ciliary epithelium detachment in all eyes before surgery and in eight of nine eyes after successful retinal reattachment. The height of the ciliary detachment, however, decreased dramatically after surgery. Although almost all the parameters between groups 1 and 2 were similar, the authors observed a significant difference in the incidence of preoperative diagnosis of ciliary detachment (P = 0.023).

CONCLUSION

Ultrasound biomicroscopy is beneficial in detecting detachment of the ciliary epithelium. The residual shallow detachment that remains after successful surgery suggests the fragility of the ciliary body.

Eosinophil peroxidase stimulates the release of granulocyte-macrophage colony-stimulating factor from bronchial epithelial cells

BACKGROUND

Asthma is characterized by an accumulation of activated eosinophils in the airway. Eosinophil viability-enhancing activity is present in the sputum of patients with asthma, largely because of granulocyte-macrophage colony-stimulating factor (GM-CSF). Bronchial epithelial cells have been shown to release cytokines including GM-CSF when stimulated with IL-1 beta or tumor necrosis factor-alpha.

OBJECTIVE

The study was designed to determine whether eosinophil peroxidase (EPO) stimulates the release of GM-CSF from bronchial epithelial cells.

METHODS

Epithelial cells (BEAS-2B) were cultured in serum free HD-F12 medium in a 24-well tissue culture plate until they became confluent. The cells were then exposed to EPO (5.9 x 10(-8) to 5.9 x 10(-7) mol/L) for 15 minutes, washed twice, and cultured in 1 ml of HD-F12. The supernatants were harvested at 3, 6, or 24 hours, and GM-CSF concentration was measured by ELISA. BEAS-2B cells were also treated with a system comprising EPO (1.9 x 10(-9) to 5.9 x 10(-8) mol/L) + 10(-5) mol/L H2O2 + 10(-4) mol/L Br for 24 hours.

RESULTS

The GM-CSF concentration in the supernatant pretreated with EPO increased in a time- and concentration-dependent manner compared with control. The release of GM-CSF was not inhibited by catalase but was inhibited by cyclohexamide and by mixing of EPO with heparin, suggesting that the action is due to the cationic property of EPO. When EPO was combined with H2O2 and Br, 5.9 x 10(-9) mol/L EPO + 10(-5) mol/L H2O2 released two times more GM-CSF into the supernatants compared with control.

CONCLUSION

These results suggest that EPO stimulates epithelial cells to release GM-CSF and forms a self-stimulatory cycle.

[A nation-wide survey for neurologic and hepato-neurologic type of Wilson disease: clinical features and hepatic copper content]

A nation-wide survey for Wilson disease was performed from 1990 to 1991. We studied clinical features and copper content in liver for the neurologic and hepato-neurologic types. A questionnaire was sent to more than five thousand hospitals in Japan. Thirty-three percent of physicians completed the questionnaire. Four hundred and twenty-five cases were studied for the onset age, primary symptoms, prognosis and hepatic copper content. The onset age of neurologic and hepato-neurologic type of Wilson disease was usually 6 years or older. The most common initial symptom was dysarthria. Gait disturbance, flapping tremor and Kayser-Fleischer rings were also very common symptoms. We conclude that in patients with dysarthria and/ or extra pyramidal symptoms over 6 years of age, Wilson disease should be considered. The prognosis quod vitam of patients with neurologic and hepato-neurologic Wilson disease is not always fatal. However, many patients required prolonged treatment at either a hospital, sanatorium or at home due to irreversibility of their severe neurological defects. This result shows that early detection is the most important factor for a promising prognosis. Copper content in liver was examined for each type of Wilson disease. Neurologic type of Wilson disease had the highest copper content, followed by hepato-neurologic type. Hepatic type had the lowest copper level out of these three forms of the disease. The mechanism of onset for each type of Wilson disease should be studied using these results.

Genotoxicity in vivo of phenazine and aminophenazines assayed in the wing spot test and the DNA-repair test with Drosophila melanogaster

The genotoxicity and DNA-damaging activity of 6 phenazine and aminophenazine derivatives were assayed in the wing spot and DNA-repair tests in Drosophila melanogaster. Phenazine (Pz), and all aminophenazines tested, namely, 1-aminophenazine (APz), 2-APz, 2,3-diaminophenazine (DAPz), 2,7-DAPz and 2,7-diamino-3,8-dimethylphenazine (DADMPz), exhibited mutagenicity significantly in the wing spot test. The activities in the wing spot test were ranked in a sequence DADMPz > (2,7-DAPz, 2,3-DAPz) > (2-APz, 1-APz, Pz). In the DNA-repair test, 2,3-DAPz, 2,7-DAPz, and DADMPz clearly showed DNA-damaging activity, but Pz, 1-APz and 2-APz were inactive. Based on these results, we predict that DADMPz, 2,3-DAPz and 2,7-DAPz are likely to be more carcinogenic than 2-APz, 1-APz or Pz.

[Indications of rethoracotomy after esophagectomy for esophageal cancer]

Indications of rethoracotomy after esophagectomy for esophageal cancer are reviewed in this paper. Hemothorax, pneumothorax, pyothorax and chylothorax are the main causes of rethoracotomy. Complications indicating rethoracotomy are summarized as follows: 1) Hemothorax; emergency rethoracotomy is indicated in cases of bleeding through the chest drain over 100ml/hr, which is continuing over 5 hours or in cases when normal blood pressure cannot be maintained without blood transfusion. In many cases the bleeding point is the chest wall, from the branches of the intercostal artery. 2) Pneumothorax; reoperation for pneumothorax is rare. But rethoracotomy and bullectomy or closure of fustula is indicated when a large volume of air leakage and lung collapse continues over a week. 3) Pyothorax; old pyothorax with bronchial fistula is treated by closure of fistula and plombage with omentum or muscle flap. 4) Chylothorax; chylothorax is not a frequent complication of esophageal surgery but when it occurs reoperation is not rare. In cases with 1,500ml/day or more of chyle drainage for over 5 days under fasting with intravenous hyperalimentation, rethoracotomy and ligation of thoracic duct is indicated.

Hypoxanthine-guanine phosphoribosyltransferase gene analysis for Japanese patients with Lesch-Nyhan syndrome

The Lesch-Nyhan syndrome results as a consequence of a severe deficiency of functional activity of purine salvage enzyme, hypoxanthine phosphoribosyltransferase (HPRT). We performed Southern blot analysis for five patients and their families using full length cDNA of the HPRT gene as a probe. Pst I digested Southern blot analysis revealed a large deletion that included exon 2 in patient 3. The size of this deletion was about 4.4 Kb. The mother of this patient had the same mutated allele and a normal one (heterozygote). This type of mutation from a Lesch-Nyhan syndrome patient has not been previously reported. The restriction fragment length polymorphism (RFLP) pattern was analyzed by Bam HI digested Southern blot analysis for one family who had no major gene abnormality. We determined from this analysis that the sister of the patient was a Lesch-Nyhan syndrome carrier and the fetus (brother) was normal for HPRT activity. This study shows RFLP analysis is still useful for carrier detection and prenatal diagnosis of Lesch-Nyhan syndrome.

Role of interleukin-4 and vascular cell adhesion molecule-1 in selective eosinophil migration into the airways in allergic asthma

Recent in vitro studies have suggested that interleukin-4 (IL-4) may be involved in the preferential migration of eosinophils into the airways in allergic asthma through its capacity to selectively increase vascular cell adhesion molecule-1 (VCAM-1) expression on vessels. To test this hypothesis, we studied the expression of VCAM-1, E-selectin, and intercellular adhesion molecule-1 (ICAM-1) on vascular endothelium in bronchial mucosal biopsies from 20 allergic asthmatics using an immunohistochemistry technique and related the observations to IL-4 levels in bronchoalveolar lavage (BAL) fluid simultaneously obtained and to eosinophil infiltration in the bronchial mucosa. IL-4 was detectable in BAL fluid from nine subjects (range, 15.1 to 110 pg/ml in 20-fold concentrated BAL fluid) (IL-4-positive asthmatics) but unmeasurable in the remaining 11 subjects (IL-4-negative asthmatics). The IL-4-positive asthmatics showed a significantly increased expression of VCAM-1 but not E-selectin and ICAM-1 on vessels as compared with both IL-4-negative asthmatics (P < 0.001) and diseased control subjects (P < 0.001). In asthmatics, VCAM-1 expression was positively correlated with BAL IL-4 levels (rs = 0.89; P < 0.0001). Moreover, there was a significant correlation between the endothelial expression of VCAM-1 and the number of eosinophils, but not neutrophils, in the bronchial submucosa (r2 = 0.76; P < 0.001). A significant correlation was also found between BAL IL-4 levels and the number of eosinophils. These results suggest that IL-4 is a VCAM-1-selective activator also in human airways and the VCAM-1-dependent pathways play a role in selective migration of eosinophils into the airways in allergic asthma, and support the hypothesis described above.

Endoscopic ultrasound-guided pancreatography: a case report

Endoscopic ultrasound-guided pancreatography was performed on a 48-year-old man with a diagnosis of pancreatic stone. A pylorus-preserving pancreaticoduodenectomy had been performed previously on this patient, approximately two years earlier, following the diagnosis of a tumor-forming pancreatitis. Endoscopic retrograde pancreatography and conventional ultrasound-guided percutaneous pancreatography had failed to yield a diagnosis. However, endoscopic ultrasound-guided pancreatography was performed successfully, delineating the pancreatic duct and a filling defect caused by intraductal calculi. Endoscopic ultrasound-guided pancreatography will be a potential alternative in cases when endoscopic retrograde pancreatography has failed or proved non-diagnostic.

Effect of YM264 on the airway hyperresponsiveness and the late asthmatic response in a guinea pig model of asthma

We investigated the effects of YM264, a specific platelet-activating factor (PAF) antagonist, on the airway hyperresponsiveness (AH) and the late asthmatic response (LAR) of guinea pigs that were sensitized by exposure to aerosolized ovalbumin (OA). Respiratory resistance (Rrs) was determined by the oscillation technique. Airway responsiveness was evaluated by administering a dose of histamine at which the Rrs reached 200% of the baseline value (H200). Animals were administered 1 or 3 mg/kg of YM264 orally 30 min before and again at 3 h after exposure to OA. YM264 significantly suppressed AH 24 h after and 5 days after the exposure. YM264 also suppressed the development of the LAR and accumulation of eosinophils and neutrophils in the tracheal mucosa of guinea pigs. These observations suggest that PAF is involved in the AH and the development of the LAR in asthma. PAF antagonists may play a beneficial role in the treatment of asthma.

[Effect of BAY u3405-thromboxane A2 receptor antagonist, on biphasic airway responses induced by platelet-activating factor in actively sensitized guinea pigs]

Our previous study in activity sensitized guinea pigs demonstrated an LAR-like increase in respiratory resistance (Rrs) at 3 to 9 hr after PAF inhalation. The result suggested possible involvement of the priming effect of active sensitization and PAF. Mean while, thromboxane A2 (TXA2) is known to be induced by PAF. The present study investigated the involvement of TXA2 in the guinea pig LAR model with a new TXA2 receptor antagonist, BAY u3405. One hr after BAY u3405 administration to guinea pigs sensitized by ovalbumin, the Rrs following inhalation of PAF was subsequently determined. Infiltration of inflammatory cells in the airway tissue 9 hr after PAF inhalation was also observed. While a re-increase in Rrs was found in all the cases in the control group, the re-increase in Rrs was inhibited significantly in the BAY u3405 administration group, 4 to 9 hr after PAF inhalation. The numbers of eosinophils and lymphocytes in the airway tissue were significantly decreased in the BAY u3405 administration group, as compared with the control group. From these results, the possibility is suggested that TXA2 and its direct effect on the airway and the migration-enhancing effect on eosinophils and T lymphocytes, as well as PFA, are involved in the development of LAR by PAF.

MRI in neurofibromatosis type I: using fluid-attenuated inversion recovery pulse sequences

Cranial magnetic resonance imaging results of 14 patients with neurofibromatosis type I were examined with T2-weighted fluid-attenuated inversion recovery pulse sequences, as well as conventional T2-weighted spin-echo sequences. Definition was better in 62 of 79 lesions or groups of lesions on fluid-attenuated inversion recovery images than on T2-weighted spin-echo images. The lesions were demonstrated not only in the brainstem, cerebellum, globus pallidus, and cerebral white matter, but also in the hippocampus, pulvinar thalami, and splenium of the corpus callosum. The latter 3 lesions have not been demonstrated or emphasized in previous studies. It is concluded that fluid-attenuated inversion recovery imaging is more effective in detecting multiple lesions in patients with neurofibromatosis type I than conventional T2-weighted spin-echo imaging.

[Wilson's disease--evolutive panorama of diagnosis and treatment in the last forty years]

In 1912, Wilson and Fleischer independently reported autopsied patients with progressive neurological disorder associated with cirrhosis of the liver, and they proposed that the syndrome could be a specific disease of toxic origin. In 1952, Scheinberg demonstrated a deficiency of serum ceruloplasmin in Wilson's disease, and it became possible to diagnose the illness while the patient was still asymptomatic. In 1956, Walshe introduced penicillamine as the most excellent drug for treatment of the disease. These epoch-making discoveries encouraged Japanese physicians to make early diagnosis and to try prevention of the disease. This lecture was to review the changing panorama in the diagnosis, treatment and prognosis of the disease in the period of forty years focusing on the experiences in Japan. Early detection of the patients based on hypoceruloplasminemia made it possible to investigate the onset ages of an elevation of serum GOT or GPT and the appearance of Kayser-Fleischer (KF) rings. So far, the youngest patients who exhibited high GPT level and KF rings were three years and five years old, respectively. It became popular that an unexpected elevation of serum transaminase in apparently healthy children of three years or more prompted to examine the possibility of Wilson's disease, and an increasing number of non-familial patients in late infancy have been detected. Now, the mass-screening for Wilson's disease is in progress. Follow-up studies on the prophylaxis for more than thirty years definitely proved that the appearance of clinical symptoms was prevented with the continued penicillamine therapy.(ABSTRACT TRUNCATED AT 250 WORDS)

Role of platelet-activating factor in the release of neutrophil and eosinophil chemotactic attractants from cultured guinea-pig tracheal epithelial cells

Platelet-activating factor (PAF) has been implicated in the pathogenesis of allergic disease, particularly bronchial asthma, by recruitment and activation of inflammatory cells. In an effort to further elucidate this function of PAF, guinea-pig tracheal mucosa was cultured in the presence of PAF in vitro, and culture supernatants were injected intradermally into normal guinea-pigs. After 6 h, recruitment of the inflammatory cells in the tissue was evaluated as a marker of chemotactic activity. Neutrophil and eosinophil recruitment increased significantly 1 h after PAF stimulation, the latter more than the former. After fractionation of the culture supernatant using molecular sieve filters, the fraction of 10-30 kDa showed greater chemotactic activity than the fractions of below 10 kDA or greater than 30 kDA. This activity was inhibited in a dose-dependent manner (over about 1-100 mg/ml) by treatment with anti-granulocyte-macrophage colony-stimulating factor (GM-CSF) antibody. These results suggest that PAF induces the release of chemotactic factors for neutrophils and eosinophils from guinea-pig tracheal epithelial cells, and one of these factors may be GM-CSF.

Effect of inhaled cyclosporin A on the allergen-induced late asthmatic response and increased in airway hyperresponsiveness in a guinea pig model of asthma

Oral administration of cyclosporin (CsA), a potent inhibitor of helper T cell function, prevents the allergen-induced late asthmatic response (LAR) and the increase in airway hyperresponsiveness (AH) seen in actively sensitized guinea pigs. The systemic administration of this agent in humans has been associated with serious side effect, therefore, the effects of inhaled CsA were therefore examined in guinea pigs that were actively sensitized by repeated exposure to nebulized ovalbumin. Respiratory resistance (Rrs) of the animals was measured by an oscillation method and the extent of AH was inferred from the inhaled concentration of histamine required to increase Rrs by 200%. The magnitude of ovalbumin-induced immediate bronchoconstriction after sensitization was similar in CsA-treated and nontreated control animals. However, a LAR was observed in 4/5 control animals but in 0/5 CsA-treated animals. The increase in AH observed 24 hours after antigen exposure in control animals was significantly inhibited by prior CsA inhalation. Significant CsA concentrations were detected by radioimmunoassay in the lungs of CsA-treated animals. Thus, inhaled CsA should be further investigated because it may be useful treating asthma while avoiding side effects.

Adenosine induces C1- efflux in endothelial cells via a pertussis toxin-sensitive G protein

To examine the biological role of adenosine A1 receptors in bovine pulmonary artery endothelial cells, we measured intracellular Cl-concentration [Cl-]i, using 10mM 6-methoxy-N-(3-sulfopropyl) quinolinium monohydrate (SPQ). N6-cyclopentyladenosine (CPA), a selective A1 agonist, at 10(-8)M to 10(-5)M, rapidly decreased [Cl-]i by 30% to 51%, without a rapid elevation in [Ca2+]i and cyclic AMP. This reduction in [Cl-]i was completely inhibited by 10(-8)M FK453 (a selective A1 antagonist), 500ng/ml pertussis toxin (IAP), and 2.5mM N-phenylanthranilic acid (NPA) (a Cl- channel blocker). We conclude that an A1 receptor in endothelial cells activates Cl- efflux via a PTX-sensitive G protein.

[A case of peritoneal metastasis of breast cancer successfully treated by multidisciplinary therapy with hyperthermia therapy]

A 53-year-old female with peritoneal metastasis of breast cancer was treated with hyperthermia with chemotherapy. One course consisted of THP 60 mg and FT 400 mg/iv (day 1), CPM 100 mg and MPA 800 mg/daily/po) with RF heating of hyperthermia monthly. After completion of 10 courses of this regimen, ascites completely disappeared and peritoneal metastases were not found observed in any peritoneal cavity with abdominal CT and ultrasound. Peritoneal metastasis of breast cancer was one of the worst reactions with any therapy. The patient has been living for about four years without any signs of recurrence, with the tumor markers within the normal range after surgery. Thermochemotherapy seems a very promising treatment modality for peritoneal metastasis of breast cancer.

Dendritic and histochemical development and ageing in patients with Down's syndrome

Mental retardation and dementia characteristic of Down's syndrome (DS) have a complex pathogenesis. Golgi and immunohistochemical studies were done on DS patients and controls from foetuses and elderly adults. Golgi studies on the cerebral cortex revealed that the postsynaptic spines on the basal dendrites increase from neonate to 15 years of age and gradually decrease after 20 years in controls, but poorly increase in children and rapidly decrease in adults with DS. This deficient synaptogenesis and dendritic atrophy may be related to mental retardation. On the other hand, immunohistochemistry on proteins, whose genes are located on chromosome 21, revealed that c-terminal protein of beta-amyloid appears in neurons of DS, S-100-positive glia increases in the hippocampus of neonates and adults, and membrane protein OK-2 is expressed earlier and is more widespread in the DS brains. The overexpression and early appearance of gene products in DS brains may be related to the pathogenesis of or predisposition to mental disorders or to dendritic hypogenesis.