[Characteristic neurological signs in patients with cervical disc disease]

In cervical radiculopathy, neurological findings for the upper extremities and the responsible level of the radices have been precisely detailed. However, in cases of cervical spondylotic myelopathy, it is not always easy to determine the responsible level of the cervical spine solely based on neurological findings. To disclose characteristic neurological lesions of the upper extremities, if any, for different locations of disc disease, 49 patients with cervical disc protrusion at single levels, confirmed by magnetic resonance imaging, were analyzed. Thirty-six patients demonstrated long tract signs (LTS) concomitant with segmental signs in the upper extremities, and 13 patients had no LTS. Except for deep tendon reflexes and the extent of dysesthesia in the upper extremities, there were no characteristic neurological findings, such as muscle atrophy, loss of muscle strength, extent of hypalgesia, or hypesthesia, pointing to the responsible compression site. In the 13 patients without LTS, the extent of dysesthesia and diminution of deep tendon reflexes proved to be completely in agreement with results for radiculopathy: 9 had protruded discs at the C56 level and described dysesthesia in the thumb and the index finger with deep tendon reflexes in the biceps and brachioradialis being diminished. The remaining 4 had protruded discs at the C67 level and described dysesthesia in the middle finger. Their deep tendon reflexes in the triceps were diminished. A clear contrast was observed for the patients with LTS. Four out of 36 patients had C34 protruded discs and did not complain of dysesthesia in any digits. Their deep tendon reflexes were exaggerated in all muscles in the upper extremities.(ABSTRACT TRUNCATED AT 250 WORDS)

Cloning, characterization, and tissue distribution of porcine SPAI, a protein with a transglutaminase substrate domain and the WAP motif

The primary and gene structures and tissue distribution of porcine SPAI-2, a protein that belongs to the WAP protein superfamily and has a sodium-potassium ATPase inhibitory activity, were determined by molecular cloning and Northern analysis. A full-length cDNA clone was isolated from a porcine duodenum cDNA library. The cDNA insert encoded a polypeptide of 187 amino acids, which is composed of three domains: a hydrophobic presequence of 21 amino acids, a prosegment of 105 amino acids ending with Asp126, and the mature SPAI-2 sequence of 61 amino acids beginning with Pro127. The prosegment contained 16 repeats of a hexapeptide that is highly homologous to the repetitive sequence found in the transglutaminase domain of the human elafin, an elastase-specific inhibitor that also belongs to the WAP superfamily. The repetitive sequence was demonstrated to be a good substrate of transglutaminase using a recombinant preparation produced in Escherichia coli. A porcine genomic library was then screened for the SPAI gene. Characterization and sequencing of positive clones indicated that the gene is similar to the elafin gene, having 3 exons encoding the 5'-untranslated region and signal sequence, proSPAI, and 3'-untranslated region, respectively. Northern blot analysis revealed intestine-specific expression of SPAI mRNA; the message was especially abundant in the small intestine. ProSPAI was also found in the circulation. The similarity of proSPAI to elafin in the domain structure, the acid-labile nature of the cleavage site (Asp126-Pro127), and the fact that the major form of SPAI in the plasma is proSPAI strongly suggest that proSPAI is not the precursor but rather it is the native form of SPAI. Like elafin, therefore, SPAI appears to be a new type of biologically active substance with a transglutaminase substrate domain that acts as an anchoring sequence.

Role of endogenous CCK in regulation of interdigestive pancreatic exocrine secretion in sheep (Ovis aries)

The role of endogenous cholecystokinin (CCK) in the regulation of pancreatic exocrine secretion during the interdigestive period was studied in conscious sheep. Intravenous infusion of proglumide (15, 30 and 60 mumol/kg/min) for 70 min significantly decreased flow rate, protein and amylase output in pancreatic juice by 80% at the maximum dose, as well as atropine (10 micrograms/kg/min), without a significant decrease in plasma concentration of immunoreactive CCK. Intravenous injection of CCK (114 pmol/kg) increased the pancreatic secretion during atropine infusion, but not during proglumide infusion. These results suggest that the regulation of interdigestive pancreatic exocrine secretion in sheep depends greatly on endogenous CCK as well as on the cholinergic mechanism.

Albumin microbubble echo-contrast material as an enhancer for ultrasound accelerated thrombolysis

BACKGROUND

Recent findings suggest that acoustic cavitation is responsible for acceleration of thrombolysis by ultrasound (US) energy. It is known that albumin microbubbles lower the threshold of acoustic cavitation production.

METHODS AND RESULTS

The present study was designed to determine whether the presence of albumin microbubbles used for echo-contrast material (Albunex) can further accelerate fibrinolysis of US. Artificial thrombus was produced by Chandler's loop method with blood extracted from a healthy subject. Urokinase (UK, 1200 IU/mL) was added to the artificial thrombi placed in test tubes. Each thrombus was exposed to US (170 kHz) at a distance of 1.2 cm for a total of 60 seconds at an intensity of 0.5 W/cm2 at intervals of 2 seconds on and 4 seconds off. Echo-contrast material (0.6 x 10(6) microspheres per mL) or 5% albumin (for control) was circulated near the thrombus at a rate of 1 mL/min during the US exposure. Fibrinolysis was later determined by percentage of weight loss of thrombus after 60 minutes of incubation (n = 15). Fibrinolysis with UK alone was 26.6 +/- 4.8%. Fibrinolysis with UK+US treatment was 33.3 +/- 5.8%. Further increase of fibrinolysis to 51.3 +/- 7.7% occurred in the presence of Albunex (UK+US+Albunex). Statistical differences were obtained between all these groups (ANOVA).

CONCLUSIONS

The presence of the echo-contrast agent induced further acceleration of thrombolysis by US energy. It is suggested that this diagnostic echo-contrast material can be used as an alternative therapeutic US drug enhancer for thrombolysis.

Doxorubicin-heparin complex: reduction of cardiotoxicity of doxorubicin

We have compared the antitumor activity and cardiotoxicity of free doxorubicin (Dox) and doxorubicin-heparin complex in vivo and in vitro. Dox and Dox-heparin complex equally inhibited the DNA synthesis of leukemic cells and showed a similar anticancer activity against tumor-bearing mice. Acute toxicity of Dox at the dose of 20 mg/kg or 30 mg/kg was significantly more profound than that of the Dox-heparin complex, which was demonstrated by survival rate (P < 0.01). Chronic toxicities of Dox and the Dox-heparin complex were compared by giving the respective reagent (2 mg/kg) weekly for 20 weeks. The weight gains of the mice given Dox-heparin complex were greater than those of the mice given Dox alone (P < 0.01). The pathological damage to the cardiac tissue in mice treated with Dox-heparin complex was significantly less severe than that of mice treated with Dox. Thus, the present study indicates that complexing with heparin diminished the acute and chronic toxicity of Dox without reducing its antitumor activity in mice, and suggests a possible clinical application of Dox-heparin complex in humans.

Restricted motion of the median nerve in carpal tunnel syndrome

Motion of the median nerve was compared on an axial ultrasonographic image in the mid-carpal tunnel in 30 wrists of 15 women with bilateral idiopathic carpal tunnel syndrome and 30 wrists of 15 healthy women. During passive flexion and extension of the index finger, the control wrists had transverse sliding of the nerve beneath the flexor retinaculum (1.75 +/- 0.49 mm), which was regarded as a physiological phenomenon. In contrast, the wrists of patients with carpal tunnel syndrome had significantly less sliding (0.37 +/- 0.34 mm; P = 0.0001), which indicates that physiological motion of the nerve is restricted. This decrease in nerve mobility may be of significance in the pathophysiology of carpal tunnel syndrome.

Latent tarsal tunnel syndrome with the provocation of flexor spasms in a paraplegic person. Case report

A 71-year-old paraplegic woman presented with a complaint of insomnia caused by severe flexor spasms of the lower limbs at night, aggravated for a few hours by taking hot baths. Lidocaine injection of the tarsal tunnel diminished the flexor-withdrawal reflex, which was easily elicited by light pinching or sustained compression over the tarsal tunnel, and strongly suggested the existence of the tarsal tunnel syndrome. Surgical decompression of the tarsal tunnel significantly reduced the flexor spasms both in terms of frequency and of duration.

Proteoglycans in haemodialysis-related amyloidosis

Changes in extracellular matrices of articular tissue, intervertebral discs and systemic organs in patients with haemodialysis-related amyloidosis were investigated by immunohistochemical and biochemical examination of proteoglycans. Increased staining for chondroitin sulfate (CS) was detected in the amyloid deposits of all patients, ranging from early to advanced stages. Degenerative tissue changes around early-stage amyloid deposits in the intervertebral discs also showed positive staining for CS. Heparan sulfate (HS) was detected in amyloid deposits, especially in the synovial membrane. Biochemical analysis of connective tissues containing amyloid supported the immunohistochemical studies; CS was the major glycosaminoglycan species in these tissues, accounting for 55-81% of the total glycosaminoglycans. Although previous studies have stressed the importance of HS in amyloidogenesis, the present study showed that CS, which increased significantly in articular tissues associated with mechanical stress, also has a close relationship with amyloidogenesis.

Effect of spinal cord stretching due to head flexion on intramedullary pressure

The effect of the longitudinal stretching force of the spinal cord on intramedullary pressure was investigated using our method for measuring intramedullary pressure of the spinal cord with implanted balloons. The transverse compressive force against the posterior wall of the spinal column was excluded by measuring the intramedullary pressure during flexion of the head with the middle and lower cervical spine in the neutral position. The intramedullary pressure of the cervical spinal cord was measured simultaneously at the C-2, C-4, and C-6 levels in 10 mongrel dogs, in three head positions: neutral, and head extension and flexion. Head flexion caused significant increases in the intramedullary pressure at C-2, C-4, and C-6. The pressure increase in the middle to lower cervical cord must have been due to the transmission of the longitudinal stretching force of the cord itself, and may be a factor in the development of intramedullary disorders such as syringomyelia and intramedullary neoplasms.

Syringomyelia secondary to tonsillar herniation caused by posterior fossa tumors

BACKGROUND

A number of patients diagnosed as having syringomyelia secondary to tonsillar herniation caused by posterior fossa tumors has recently been described, although the backgrounds of the affected patients were not studied. In order to determine the possible causative contribution of the tonsillar herniation, the present cooperative study was carried out.

METHODS

A retrospective study was performed by five cooperating institutes. Magnetic resonance images (MRIs) of patients with posterior fossa tumors were reevaluated with particular attention to the existence of tonsillar herniation and syringomyelia.

RESULTS

The total number of patients with posterior fossa tumors whose MRIs were reinvestigated was 164. In 24 out of the 164 patients, tonsillar herniation was apparent in the sagittal plane of the MRI. Syringomyelia was observed in five of the 24 cases with tonsillar herniation being a consistent associated finding. None of the individuals demonstrated any sensory disturbance directly corresponding to the syrinx formation. All but one of the five patients underwent surgical removal of the tumor, but no one required surgical treatment for the syrinx itself. Disappearance or shrinkage of the syrinx could be confirmed by postoperative MRIs in three of them.

CONCLUSIONS

A simple mechanism of blockage of cerebrospinal fluid flow at the foramen magnum may play an important role in syrinx formation, as evidenced by the unexpectedly high incidence of cervical syrinx along with tonsillar herniation caused by posterior fossa tumors shown in the present study.

G-related musculoskeletal spine symptoms in Japan Air Self Defense Force F-15 pilots

The introduction of the F-15 Eagle to the Japan Air Self Defense Force (JASDF) in the early 1980's seemed to increase musculoskeletal problems of the spinal column among pilots. The neck is the body part most vulnerable to high-G force injuries, and serious cases of neck injury have been reported. We surveyed 129 F-15 pilots from different air bases by means of a questionnaire. The occurrence rate of musculoskeletal problems in different types of aircraft was analyzed according to the pilots' flying experience. Of the surveyed pilots, 115 (89.1%) reported muscle pains related to flying. Of those who experienced pain, each averaged 7.6 events, 95% of which occurred in the F-15. Of these 115, 30% experienced pain in the F-4 and 15% in the F-1. The "checking six" position was the most common posture at the time of injury, followed by "forward bend." Of the 115 pilots, 44 stated that their symptoms adversely affected flight duty performance, and 50 pilots stated that their symptoms adversely affected daily life. The effectiveness of muscle training as a preventive measure was supported by 62%. Some oriental therapeutic methods (acupuncture, moxa cautery, and finger-pressure massage) were preferred by pilots for pain treatment. G-related problems of the spinal column still exist as a major medical concern in JASDF.

Spinal cord intramedullary pressure: direct cord traction test

Spinal cord intramedullary pressure was measured in eight mongrel dogs using a balloon method. The neck of the animals was maintained in the neutral position. Following cervical laminectomy, the cervical spinal cord was drawn dorsally using a small plastic saddle inserted ventral to the spinal cord at the C-5 level. The cord pressure at C-5 increased with traction load. The cord pressure at C-6 not in direct contact with the plastic saddle also increased to about one third the increase at C-5. These findings indicate that spinal cord intramedullary pressure is increased by mechanical compression on the anterior structure of the spinal canal and stretching of the cord to some extent. This phenomenon might be important in cord insult in patients with spinal column lesions located anterior to the spinal cord and presenting with neurological signs extending over several segments.

[A case of synchronous double cancer in the same pulmonary lobe]

We have experienced a case of synchronous double cancer developing in the right lower lobe in a 75-year-old male. He was asymptomatic. His chest X-ray film showed two nodular shadows, one in the right proximal S8 and another in peripheral S9. The serum CEA level was elevated to 9.5 ng/ml. Bronchoscopic brush cytology revealed adenocarcinoma from the tumor in orifice of B8. He was therefore diagnosed preoperatively as having adenocarcinoma of the right S9 with metastasis to #12 hilar lymph node. Right lower lobectomy was performed. The final histological diagnosis was double primary lung cancer consisting of squamous cell carcinoma (S9) with rare mucoepidermoid carcinoma in the same lobe. His postoperative course was uneventful.

Successful treatment by surgical removal of bone metastasis producing PTH: new approach to the management of metastatic parathyroid carcinoma

A 62-year-old woman had primary hyperparathyroidism due to parathyroid carcinoma. In spite of surgical removal of the enlarged parathyroid gland, intractable hypercalcemia persisted. 99mTc-methoxyisobutylisonitrile scanning revealed bone metastatic lesions, although conventional 201T1-chloride scanning failed to demonstrate those lesions. Octreotide inhibited parathyroid hormone (PTH) secretion, although various means such as bisphosphonates, calcitonin and hydration were effective to reduce serum calcium level to some extent but failed to reduce PTH secretion at all. The CT-guided transcutaneous tumor marking facilitated the subsequent orthopedic surgery for successful removal of the metastatic focus of PTH secretion from the iliac bone.

An androgen receptor mutation causing androgen resistance in undervirilized male syndrome

The molecular basis of androgen resistance was investigated in a patient with undervirilized male syndrome. Binding studies of the androgen receptors in the patient's genital skin fibroblasts revealed a normal binding capacity of 5 alpha-dihydrotestosterone, although the affinity to androgen was slightly lower than the normal control value. The androgen binding of the patient's receptor showed a moderate thermal instability when the assay temperature was raised from 30 to 41 C. Nucleotide sequencing analysis of the androgen receptor gene revealed a single nucleotide substitution in exon F, resulting in an amino acid alteration from leucine (CTC) to phenylalanine (TTC) at position 789 within the steroid-binding domain of androgen receptor. When expressed in COS-7 cells, the mutant androgen receptor harboring phenylalanine at position 789 showed thermolabile androgen-binding properties similar to those observed in the patient's genital skin fibroblasts. Cotransfection experiments with an androgen-inducible reporter gene demonstrated a decreased transactivational capability of the mutant receptor. These results indicate that this point mutation modified the receptor function and caused androgen resistance in this patient. This mutation caused the mildest form of all androgen insensitivity syndromes ever examined for mutations in the androgen receptor gene.

Spinal cord intramedullary pressure. A possible factor in syrinx growth

STUDY DESIGN

This study analyzed biomechanical characteristics of the cervical spinal cord, especially in relation to neck flexion. Intramedullary pressure was measured in different neck positions.

OBJECTIVES

The results provided a rationale for dynamic changes in intramedullary pressure, with the flexed neck position playing a role in syrinx growth.

SUMMARY OF BACKGROUND DATA

Dynamic changes in intramedullary pressure in the flexed position have been postulated to play an important role in syrinx growth. However, intramedullary pressure of the spinal cord has not been measured.

METHODS

The authors designed a balloon method to assess, experimentally, intramedullary pressure dynamics of the spinal cord. A system was incorporated to examine the reliability of the balloons. Using 15 mongrel dogs, two balloons were embedded in the cervical spinal cord. Intramedullary pressure of the spinal cord was measured in several neck positions. In 5 of them, the same measurements were repeated when the spinal cord and roots were transected.

RESULTS

When filled with a suitable volume of water, the balloons faithfully transmitted the pressure of the environment. No pressure differences were observed with the neck in the extended or neutral positions. However, when the neck was flexed, intramedullary pressure significantly increased. This increase in intramedullary pressure in the flexed neck position was not observed after spinal cord and roots were transected.

CONCLUSION

The results indicated that the intramedullary pressure of the cervical spinal cord increases when the neck is flexed. This phenomenon might play an important role in syrinx growth.

[Metastasis of an adenocarcinoma of unknown origin to mediastinal lymph nodes, and transient regression]

A 67-year-old woman was admitted to our hospital because of fever. Chest roentgenogram showed an enlargement of mediastinal lymph nodes. Despite thorough examination, no definite diagnosis could be made. The mediastinal lymph nodes got smaller over the next 3 weeks and a chest roentgenogram taken 4 months later showed no mediastinal lymphadenopathy. The mediastinal lymphadenopathy and fever recurred 5 months later. She underwent thoracotomy and the mediastinal lymph nodes were excised. Microscopic examination of pretracheal lymph node specimens showed invasion of poorly differentiated adenocarcinoma associated with abundant tumor-infiltrating lymphocytes. The other lymph nodes showed sarcoid reaction. Although she has been followed for one year and 11 months, no primary site of the cancer has been found. Metastasis of cancer of unknown origin to mediastinal lymph nodes is extremely rare. It is also interesting that the lymph node swelling diminished spontaneously. The tumor-infiltrating lymphocytes and sarcoid reactions may have been immunological responses to the cancer and may have caused the transient regression.

[Severe obstructive necrotizing enterocolitis associated with carcinoma of the sigmoid colon: report of a case]

A 68-year-old male diagnosed as carcinoma of the sigmoid colon developed shock and cardiac arrest just 8 hours after the onset of ielus. After resuscitation, exploratory laparotomy was carried out and it revealed gangrene spreading from the sigmoid colon over the distal 150cm of the terminal ileum, separated from the carcinoma by a normal segment of the colon 13cm in length. All the mesenteric vessels were pulsating normally. The whole necrotic lesion including the carcinoma was resected and an ileostomy was constructed. This is a noteworthy report of severe obstructive necrotizing enterocolitis with critical condition and wide involvement of the colon and intestine associated with carcinoma of the sigmoid colon.

Closed rupture of the flexor digitorum profundus tendon within the carpal tunnel

We report a case of a closed rupture within the carpal tunnel of the flexor digitorum profundus tendon of the little finger. There was no underlying pathology.

Liver tissue damage by ultrasound in combination with the photosensitizing drug, Photofrin II

We have investigated whether ablation of normal rat liver by ultrasound can be enhanced after administration of a photosensitizing agent (Photofrin II). After laparotomy and administration of Photofrin II (30 mg/kg), ultrasound (210 kHz, 1.3 W/cm2) was directed directly to the surface of the liver for a total duration of 3 min by a plane type unfocused transducer (6 mm x 6 mm). The depth of tissue damage was histologically compared to rats exposed to ultrasound alone. The mean maximum lesion depth on rats applied with ultrasound and Photofrin II was 5.7 +/- 0.9 mm (mean +/- SD) whereas in rats treated with ultrasound alone this was 3.0 +/- 0.4 mm. There was a significant difference between the two groups (P < 0.05). The present study suggests the possible use of a photosensitizing agent as an enhancer for the treatment of liver tumors by ultrasound.

[A case of crescentic glomerulonephritis associated with anti-myeloperoxidase antibody presenting as alveolar hemorrhage]

A 77-year-old man was admitted because of hemoptysis. Chest roentgenograms initially showed progressive infiltrative shadows, which improved spontaneously in 3 months. Transbronchial lung biopsy specimens obtained during the first admission revealed alveolar hemorrhage with neither granuloma nor vasculitis. Alveolar hemorrhage associated with renal dysfunction recurred 9 months later. Serum creatinine level was elevated to 3.5 mg/dl. No other organ than lungs or kidneys was involved. Renal biopsy was performed to confirm the pathological diagnosis of crescentic glomerulonephritis. Anti-basement-membrane antibody was negative, whereas anti-neutrophil-cytoplasmic antibody was positive for perinuclear pattern (P-ANCA) by indirect immunofluorescent (IF) method. He was diagnosed as having idiopathic crescentic glomerulonephritis complicated with alveolar hemorrhage, and the presence of anti-myeloperoxidase (MPO) antibody in serum was anticipated. Anti-MPO antibody level in his serum evaluated by ELISA was markedly elevated. Although myeloperoxidase has been considered as a common antigen to P-ANCA and anti-MPO antibody, the determination of P-ANCA has been clinically unreliable because of equivocal results. In contrast, the presence of anti-MPO antibody is highly specific for idiopathic crescentic glomerulonephritis complicated with alveolar hemorrhage or its incomplete variant case. Also, it is a better index of disease activity. Therefore, there is a possibility that those patients diagnosed as having idiopathic pulmonary hemosiderosis or pulmonary-renal syndrome may be categorized into the one disease, anti-MPO antibody-associated disease, and the measurement of anti-MPO antibody may lead to prompt treatment prior to the histological diagnosis.

Elastase inhibitor elafin is a new type of proteinase inhibitor which has a transglutaminase-mediated anchoring sequence termed "cementoin"

Elafin was shown to be a new type of proteinase inhibitor which has an anchoring sequence. Human elafin, a potent inhibitor specific for elastase and proteinase 3, has a unique repeating sequence in its prosegment that is rich in Gln and Lys residues. The prosegment, termed "cementoin," exhibits high homology with the repetitive element of seminal vesicle clotting protein, which is known as a good substrate for prostate transglutaminase. The cross-linking of cementoin by tissue transglutaminase showed that the cementoin moiety is indeed a preferable substrate for transglutaminase. In addition, transglutaminase-mediated cross-linking between cementoin and laminin was observed in vitro, suggesting that cementoin has the ability to covalently attach to other extracellular matrix proteins. To determine whether or not this type of covalent gluing of elafin through the cementoin moiety occurs in vivo, we determined the molecular size of cementoin-elafin in the trachea mucous epithelium by Western blotting; the rationale of this approach is that (i) the trachea is the richest source of cementoin-elafin, as shown below, and (ii) if cementoin-elafin is covalently associated with other proteins, it should migrate as a higher M(r) species on SDS-polyacrylamide gel electrophoresis; cementoin-elafin immunoreactivity was indeed detected at a position corresponding to 50 kDa, a value much higher than that of its monomeric form. RNase protection analysis and immunohistochemical staining revealed that cementoin-elafin is densely distributed in the skin and trachea, and moderately in the stomach, duodenum and small intestine. These sites of localization are consistent with the locations where elastic fibers are abundant.(ABSTRACT TRUNCATED AT 250 WORDS)

Serum levels of major basic protein in patients with or without eosinophilia: measurement by enzyme-linked immunosorbent assay

A bone marrow proteoglycan (BMPG) has been purified which consists of the same amino acid sequence as that of pro-MBP, and produced two anti-BMPG mAbs. Serum levels of major basic protein (MBP), a cationic protein rich in the eosinophil granule, were measured in patients with eosinophilia or allergic diseases by an enzyme-linked immunosorbent assay (ELISA) using these mAbs. The serum levels of MBP in patients with eosinophilia (n = 64) and in those with allergic diseases without eosinophilia (n = 32) were elevated significantly (P < 0.001 and P = 0.038, respectively). There was a weak positive correlation between the serum levels of MBP and the eosinophil counts in the patients with eosinophilia (r = 0.38). Among these patients, extremely high serum levels of MBP were found in those with hypereosinophilic syndrome (HES) and Kimura's disease. Serum levels of MBP decreased more slowly than the eosinophil counts in patients with eosinophilia when treated by glucocorticoids. We conclude that measurement of serum levels of MBP is useful in evaluating the total-body proliferation and infiltration of eosinophils more accurately than following-up the eosinophil counts alone.

Familial carpal tunnel syndrome due to amyloidogenic transthyretin His 114 variant

We studied two patients from a Japanese family with carpal tunnel syndrome (CTS). The biopsy samples obtained during CTS surgical release revealed deposits of amyloid that stained with antihuman transthyretin (TTR) antiserum. Single-strand conformation polymorphism analysis and sequence analysis of polymerase chain reaction (PCR)-amplified exons of the proband's TTR gene revealed a point mutation resulting in a substitution of histidine for tyrosine at position 114. The mutation was confirmed by PCR-primer-induced restriction analysis. Our findings account for clinical heterogeneity of TTR-derived amyloidosis, and suggest the importance of substitution itself for deposits of amyloid in CTS.