[Case report: rheumatoid arthritis complicated by chronic myelogenous leukemia treated with interferon]

A fifty-six-year old man complained of arthralgia and swelling of both feet, morning stiffness in both hands and finger joints in March 1987, and was treated with non-steroidal anti-inflammatory agents at another hospital. He has been treated for chronic myelogenous leukemia (CML) since May 1990. He was admitted to our hospital in March 1991 because of worsening of his multiple arthralgias, and a diagnosis of rheumatoid arthritis (RA) (Stage I, Class 2) was made on the basis of gait disturbance, arthralgia persisting for more than 6 weeks, the presence of subcutaneous nodules and X-ray findings. CML was confirmed by peripheral blood and bone marrow findings and the presence of the Philadelphia chromosome and bcr gene rearrangement. High fever and dyspnea developed suddenly 3 days after administration of interferon in May 1991. In addition to pneumonia, a leucostasis was suspected and he was treated with high dose steroids and antibiotics. After improvement, the steroids were tapered and he was discharged from hospital in July 1991.

The first case of polymyositis associated with interferon therapy

A 54-year-old man with renal cell carcinoma was treated with interferon (IFN)-gamma for 3 weeks soon after nephrectomy. Three months later he received IFN-alpha therapy for 8 weeks due to chronic active hepatitis C. He subsequently contracted polymyositis (PM): proximal muscle weakness, an elevation of muscle enzymes, myogenic patterns on the electromyograph and histologically specific findings in biopsied muscle specimens. After discontinuation of IFN his muscular weakness gradually recovered.

[Thoracic outlet syndrome due to first rib anomaly: a case report]

Compared to cervical rib, first rib anomaly is less familiar to us as a cause of thoracic outlet syndrome. We report a case of thoracic outlet syndrome due to first rib anomaly. A 50-year-old man was admitted to our hospital because of right arm pain when his arm was raised up. Chest X-ray showed an abnormal right first rib which made a J-shaped curve and was attached to the second rib. A palpable mass was noted in the supraclavicular region. Angiography revealed complete occlusion of the right subclavian artery in the Allen test position. During conservative therapy for two months, the symptom was gradually getting worse. We performed resection of the right first rib and anterior scalenotomy by the supraclavicular approach. The patient made a good recovery after the surgery. Postoperative angiogram showed no stenotic lesion of the right subclavian artery. If a patient has complaints suggesting compression of the subclavian neurovascular bundle, we should be careful not to overlook the first rib anomaly on chest X-ray.

Halo congenital nevus undergoing spontaneous regression. Involvement of T-cell immunity in involution and presence of circulating anti-nevus cell IgM antibodies

BACKGROUND

Halo congenital nevus is a condition in which halo formation is associated with congenital nevocellular nevi. Although several theories have been proposed, the immunologic mechanisms of halo formation and concomitant nevus regression still remain unclear. We presented immunologic findings in a case of halo congenital nevus with unique histologic location of inflammatory cells.

OBSERVATIONS

Histologically, the present case of halo congenital nevus undergoing spontaneous regression showed a marked inflammatory infiltrate with remnants of original nevus cell nests. In the infiltrating T cells, CD8+ cells outnumbered CD4+ cells and the infiltrate of natural killer cells was not substantial. Direct and indirect immunofluorescence studies demonstrated the presence of IgM antibodies against nevus cells as well as melanoma cells and cultured melanocytes in the patient's serum.

CONCLUSIONS

Our findings suggest that both T-cell-mediated immunity and IgM antibodies may be involved in the regression of halo congenital nevus. However, it is important to point out that our results may simply be epiphenomena and not directly responsible for the destruction of nevus cells.

Experimental study of the mechanism of seizure induction: changes in the concentrations of excitatory amino acids in the epileptic focus of the cat amygdaloid kindling model

L-glutamate (Glu) and L-aspartate (Asp) are two major excitatory amino acids that may be involved in seizure susceptibility and seizure induction. The concentrations of Glu and Asp were measured by microdialysis in the epileptic focus in a cat amygdaloid kindling model. Sequential changes in Glu and Asp (before, during, and after seizure) were measured in the partial seizure (S4) and generalized seizure (S6) groups. By stimulation at and 50 microA below the partial seizure-triggering threshold in the S4 group and the generalized seizure-triggering threshold in the S6 group, Glu was released from the epileptic focus in the S4 group, and both Glu and Asp were released in the S6 group after seizure and stimulation (below threshold), and the amount of Glu and/or Asp release determined seizure induction. Excitatory amino acids may be the trigger of seizure induction in the cat amygdaloid kindling model.

Medulloblastoma associated with cysts and calcifications--case report

An 11-year-old boy presented with medulloblastoma occurring in the cerebellar vermis. Computed tomography and magnetic resonance imaging revealed numerous cysts and calcifications in the tumor. The tumor was subtotally removed and cellular synchronization radiation therapy given. He was discharged without neurological deficits. Histological examination showed the cysts represented necrotic foci. Macrophages, which appeared around the necrotic foci, were important in the development of the calcifications via proliferation of collagen fibers.

Meningioangiomatosis not associated with von Recklinghausen's disease--case report

A 7-year-old girl with meningioangiomatosis not associated with von Recklinghausen's disease is described. The radiological findings were similar to meningioma, but intraoperatively, a thin septum was found between the mass and the dura mater. Microscopically, there was significant proliferation of fibroblastic spindle-shaped cells and collagenous fibers in the subarachnoid space. Proliferated cells had penetrated into the cortical tissue along the irregularly branched blood vessels. Immunohistochemically, these penetrating perivascular cells were negative for glial fibrillary acidic protein and S-100 protein, and positive for vimentin staining. These findings suggest that the histogenesis of the spindle-shaped cells is most probably meningothelial.

Long-term carriage of hepatitis C virus with normal aminotransferase after interferon treatment in patients with chronic hepatitis C

Studies were undertaken to investigate whether interferon therapy could induce hepatitis C virus (HCV) carriage with normal serum alanine aminotransferase (ALT) values using an assay that combined reverse transcription and polymerase chain reaction. The subjects studied were 53 patients with chronic active hepatitis C who received interferon (alpha, 33 cases; beta, 20 cases) therapy. All were seropositive for HCV RNA prior to therapy. In all 22 complete responders, whose ALT levels fell to normal during therapy and for at least 24 weeks after therapy, HCV RNA became persistently negative except in two cases. The two had sustained viremia on treatment and for 1.0-1.5 years of follow-up, although their biochemical tests were normal. In 15 patients with a transient response in whom the disease recurred when interferon was stopped, HCV RNA was undetectable in 80% of the cases at the end of therapy, but the virus reappeared with subsequent elevation of ALT in all patients. However, 3 patients in this group had normal enzyme levels with viremia for 2.1-2.8 years of follow-up after acute deterioration of illness. In 16 patients who did not respond to interferon, HCV RNA was persistently positive during and after therapy. These findings suggest that interferon therapy induces a long-term carrier state of HCV infection with normal ALT levels in some patients.

Effects of interferon-alpha treatment on hepatitis B virus antigen-specific immunologic responses in patients with chronic hepatitis B

Studies were undertaken to evaluate the relationship between the immune responses and the effectiveness of interferon-alpha treatment in 21 patients with HBeAg-positive chronic active hepatitis. Peripheral blood mononuclear cells (PBMC), obtained on four occasions during an 8-week course of IFN-alpha therapy, were cultured with recombinant HBcAg, purified HBeAg or pokeweed mitogen (PWM). During follow-up for 6 months after therapy, clearance of serum HBeAg was observed in eight patients designated as responders. Immunological responses of PBMC obtained before treatment did not differ between responders and non-responders. In responders, IFN-gamma and anti-HBc production was depressed during therapy, but recovered to above the pretreatment level at the end of and/or after cessation of therapy, while lymphocyte proliferation was enhanced during therapy with a subsequent decline to baseline value. In non-responders, such changes were modest throughout the study, and anti-HBc response remained decreased even after cessation of therapy. These results indicate that PBMC of responders have immunologically different responses to IFN-alpha therapy when compared with non-responders.

Localisation of intrahepatic interleukin 6 in patients with acute and chronic liver disease

AIM

To evaluate the role of local interleukin 6 (IL-6) in the pathogenesis of acute and chronic liver disease.

METHODS

The cellular site of IL-6 in cryostat sections of liver from 31 patients with liver disease was examined using indirect immunofluorescence with a monoclonal antibody.

RESULTS

IL-6 staining in sinusoidal endothelial cells was very noticeable and diffusely distributed in the lobules of specimens of acute viral hepatitis. IL-6 expression in endothelial cells, particularly in necrotic areas of hepatocytes, was increased and was accompanied by enhanced expression in Kupffer cells. In contrast, IL-6 staining in infiltrating mononuclear cells was prominent in portal tracts, and the numbers of cytokine positive cells were greater in specimens of chronic active hepatitis compared with chronic persistent hepatitis. In non-specific reactive hepatitis intrahepatic expression of IL-6 was minimal, while in alcoholic liver fibrosis the cytokine distribution in the lobules was similar to that of acute viral hepatitis.

CONCLUSIONS

These results indicate that locally produced IL-6 contributes to the inflammatory process and immunological response in acute and chronic liver disease.

Noninvasive evaluation of the magnitude of aortic and mitral regurgitation by means of Doppler two-dimensional echocardiography

Using transmitral flow velocity and left ventricular ejection flow velocity, we measured left ventricular inflow volume (LVIV) and left ventricular outflow volume (LVOV) by pulsed Doppler echocardiography in 73 patients who had mitral valve regurgitation (MR), aortic valve regurgitation (AR), or no valvular regurgitation. Doppler-determined regurgitant volume (DOPRV), Doppler-determined regurgitant fraction (DOPRF), total stoke volume, and forward stroke volume were calculated to compare the severity assessed by angiographic scoring and the regurgitant fraction determined by radionuclide angiography (RIRF). In 17 patients with MR, LVIV (84.4 +/- 20.4 ml) was significantly greater (p less than 0.01) than LVOV (52.5 +/- 15.7 ml). LVOV, which is equivalent to forward stroke volume, was lower in patients with MR (52.2 +/- 15.7 ml) than in normal subjects (67.0 +/- 15.7 ml). In 15 patients with AR, LVOV (121.7 +/- 61.1 ml) was significantly greater (p less than 0.01) than LVIV (75.1 +/- 28.1 ml) and LVOV, which is equivalent to total stroke volume, was greater in patients with AR (121.7 +/- 61.1 ml) than in normal subjects (64.0 +/- 14.4 ml). DOPRF correlated with RIRF (r = 0.79, p less than 0.01, n = 11). DOPRV (mild: 10.5 +/- 8.5 ml; moderate: 28.8 +/- 13.6 ml; severe: 74.5 +/- 36.7 ml) and DOPRF (mild: 13.7% +/- 11.5%; moderate: 33.1% +/- 14.2%; severe: 52.6% +/- 15.3%) increased markedly with the severity of regurgitation as assessed by cineangiography. In AR, total stroke volume influenced both forward stroke volume and regurgitant volume, and in MR, regurgitant volume influenced both total stroke volume and forward stroke volume. Total stroke volume in AR and regurgitant volume in MR may play a key role in valvular regurgitation.

Comparisons of peripheral blood and hepatic lymphocyte subpopulations and interferon production in chronic viral hepatitis

Studies were undertaken to clarify the immunological mechanism in patients with chronic hepatitis C compared with chronic hepatitis B. Phenotypic study by flow cytometry showed that CD8+ T cells and HLA-DR+ cells isolated from liver biopsy specimen were significantly increased in their proportions as compared with those in peripheral blood, while intrahepatic CD4+ T cells were significantly lower than peripheral blood CD4+ T cells in both types of patients with chronic active hepatitis (CAH). Furthermore two-color analysis revealed that CD8+ CD11- and CD3+ HLA-DR+ cells were significantly elevated in liver tissue than in peripheral blood in both patients groups. In in vitro tests, mononuclear cells obtained from the liver of type B and type C CAH had a reduced capacity to produce IFN-gamma in response to pokeweed mitogen, while they produced equal amounts of IFN-alpha under stimulation with Newcastle disease virus as compared with control peripheral blood mononuclear cells. In contrast, spontaneous productions of both IFNs were greater in liver infiltrates of the two patients groups. These results indicate that functionally activated T cells are distributed in a similar manner in the liver of both chronic hepatitis B and C, suggesting that cytotoxic T cell plays a major role in the hepatocellular injury of both groups of patients.

Hemodynamic changes by recombinant erythropoietin therapy in hemodialyzed patients

Recombinant human erythropoietin therapy was given to 15 patients undergoing long-term hemodialysis with normal cardiac function. None of the patients had hypertension before the erythropoietin therapy and had received no antihypertensive agents. Before and after the erythropoietin therapy M-mode and pulsed Doppler echocardiographic studies, measurements of plasma volume by radioiodinated human serum albumin, and measurements of atrial natriuretic factor were carried out. After 6 weeks of erythropoietin therapy, hematocrit increased from 20.0 to 33.0%. Cardiac output, stroke volume, left ventricular diastolic dimensions, and left ventricular wall stress were all significantly decreased. Total peripheral resistance, interventricular septal thickness, and left ventricular posterior wall thickness were significantly increased. In Doppler echocardiographic studies, the mean velocity of aortic ejection flow and left ventricular acceleration time were decreased. The blood volume derived from plasma volume and hematocrit was not changed, whereas plasma atrial natriuretic factor concentration was significantly decreased. These data suggest that recombinant human erythropoietin administration suppressed the hyperdynamic cardiac state that was required to maintain oxygen delivery to the peripheral tissues in severe uremic anemia.

Induction of polymorphonuclear leukocyte-derived hepatocyte stimulating factor and effects on alpha 2-macroglobulin synthesis

We investigated the kinetics of production of the hepatocyte stimulating factor (HSF) by peritoneal exudate- and peripheral circulating blood-polymorphonuclear leukocytes (PMNLs). Effects of the HSFs on alpha-2-macroglobulin (a2M) synthesis and a2M specific gene expression in primary cultured adult rat hepatocytes were also examined. Peritoneal exudate-PMNLs were collected 3 hr after the injection of alkaline-denatured casein into the peritoneal cavity of rats. Secretion of HSF into the culture medium began within 15 min after the start of incubation and practically a full secretion was noted within 3 hr. Lipopolysaccharide or other agents were not required to induce HSF from the PMNLs. Inhibitors of protein or DNA synthesis, cycloheximide, actinomycin D or puromycin, did not inhibit the secretion of HSF by rat PMNLs thereby suggesting that preformed and pooled HSF in the PMNLs was secreted during incubation. Peripheral circulating blood-PMNLs collected from a healthy man did not secrete HSF, in the absence of stimulation but did secrete HSF after vigorous agitation during incubation at 37 degrees C. The PMNL-HSF induced the synthesis of a2M and the accumulation of a2M mRNA in primary cultured rat hepatocytes. However, the effect was evident only with dexamethasone present in the culture medium. Furthermore, the effects of the PMNL-HSFs on a2M and albumin protein synthesis were reciprocal: The PMNL-HSF induced a2M synthesis, whereas it suppressed albumin synthesis.

Phorbol ester dissociates endothelin-stimulated phosphoinositide hydrolysis and arachidonic acid release in vascular smooth muscle cells

Endothelin-stimulated [3H]-inositol phosphate formation and [3H]-arachidonic acid release were measured in cultured vascular smooth muscle cells from rabbit renal artery. Both responses were partially inhibited by pretreatment with pertussis toxin, indicating the involvement of pertussis toxin-sensitive guanine nucleotide binding regulatory proteins in the coupling processes. Pretreatment with the phorbol ester PMA inhibited endothelin-stimulated [3H]-inositol phosphate formation, but potentiated endothelin-stimulated [3H]-arachidonic acid release, suggesting that these two coupling processes occur in a parallel and independent manner in vascular smooth muscle cells.

[Effect of recombinant human erythropoietin administration on cardiovascular system in patient with chronic renal failure: an analysis of the blood pressure upward]

To investigate the mechanism of blood pressure upward after recombinant human erythropoietin (EPO) administration in patient with chronic renal failure (CRF), hemodynamic changes following on the improvement of anemia was evaluated by the echocardiography. Fourteen (5 males, 9 females) normotensive patients with less than 23% of hematocrit (HT) were administered 1,500 approximately 3,000 units of EPO three times a week. Four patients with systolic (greater than 160 mmHg) or diastolic (greater than 90 mmHg) hypertension after EPO administration was named group H, the remaining patients was named group N. Blood pressure, heart rates and parameters of echocardiography examined after the improvement of anemia were compared to those examined before EPO administration, respectively. Patients had an increase in Ht from 20.0 +/- 1.6% to 33.0 +/- 1.9% (p less than 0.01). LVDd, LVEDV, CO and flow velocity in group N were significantly decreased after EPO administration; while those in group H did not show the significant changes. IVSth and LVPWth in each group were significantly increased after EPO administration. These data showes that decrease in CO maintains the patients normotensive after EPO administration.

Kupffer cells may autoregulate interleukin 1 production by producing interleukin 1 inhibitor and prostaglandin E2

Rat Kupffer cells stimulated with bacterial lipopolysaccharide (LPS) produced high levels of interleukin 1 (IL-1), as determined by thymocyte proliferation assay. Indomethacin revealed a dose-dependent augmentation in IL-1 production, in parallel with a dose-dependent reduction in prostaglandin E2 production by Kupffer cells. The addition of exogenous prostaglandin E2, dibutyryl cAMP, or isoproterenol led to a dose-dependent suppression of IL-1 production. The supernatant from LPS-stimulated Kupffer cells also contained factors that inhibited IL-1-induced thymocyte proliferation. Upon gel filtration, two inhibitory peaks, at apparent MW of 27,000 and 6000, were obtained. The latter but not the former fraction also affected interleukin 2 (IL-2)-induced thymocyte proliferation. Increasing amounts of IL-1 overcame the inhibitory activity derived from the 27,000 MW fractions. These results suggest to us that prostaglandin E2 and IL-1 inhibitor released by Kupffer cells may be involved in negative self-control in regulating IL-1 production and its action.

Kinetics and parameters of the induction of interleukin 1 secretion by rat Kupffer cells

Rat Kupffer cells stimulated with bacterial lipopolysaccharide (LPS) produced high levels of interleukin 1 (IL-1), determined by assaying the thymocyte proliferating activity. The unstimulated Kupffer cells secreted no detectable activity. LPS-induced production of IL-1 activity was dose-dependent and as little as 0.1 micrograms/ml of LPS induced the IL-1 production. Thirty minutes were required for LPS to induce sufficient amounts of IL-1 activity. IL-2 activity was not detected in the Kupffer cell culture medium. Another soluble agent, N-acetylmuramyl-L-alanyl-D-isoglutamine, or phagocytable agents, silica and zymosan, also stimulated IL-1 production by Kupffer cells, whereas phorbol myristate acetate did not. Kinetic studies revealed a rapid increase in both intra- and extracellular IL-1 activity within 1 hr following the addition of LPS, with a peak at 6 hr. This IL-1 activity produced by Kupffer cells was heat labile, resistant to freezing and thawing and precipitated with 65% ammonium sulfate. Upon gel filtration, the activity was present in three peaks of approximately 110, 35 and 15 kd. The hepatocyte stimulating activity, when assayed by alpha 2-macroglobulin inducing activity, was detected in the first two peaks but not in the third peak. These studies suggest that LAF activity is distinct from hepatocyte stimulating activity at least in the molecular weight.

Noninvasive evaluation of the ratio of pulmonary to systemic flow in ventricular septal defect by means of Doppler two-dimensional echocardiography

Left ventricular inflow volume (LVIV) and outflow volume (LVOV) were determined by pulsed Doppler echocardiography, and the ratio of pulmonary to systemic flow (Qp/Qs) was estimated as a ratio of LVIV to LVOV (LVIV/LVOV). Seventy-seven patients were studied, 47 control subjects and 30 patients with ventricular septal defect (VSD). LVOV was calculated from the left ventricular ejection flow velocity and left ventricular outflow tract diameter; LVIV was calculated from the transmitral flow velocity and mitral valve motion as traced by M-mode echocardiography. Cardiac input (COin) and cardiac output (COout) were calculated as the product of LVIV or LVOV and heart rate. Cardiac output was also determined by the dye dilution method (COdye) in control subjects. A close correlation was observed between COdye and COin (y = 1.18x - 243, r = 0.85, p less than 0.005, SEE = 1026 ml/min) and COdye and COout (y = 1.16x - 323, r = 0.90, p less than 0.005, SEE = 639 ml/min). LVIV and LVOV were highly correlated in control subjects (y = 0.95x + 5.3, r = 0.94, p less than 0.005, SEE = 6.6 ml). LVIV/LVOV was 0.97 +/- 0.1 (mean +/- SD) in control subjects, whereas LVIV/LVOV (1.87 +/- 0.88) was significantly higher in patients with VSD (p less than 0.01). In patients with VSD, LVIV/LVOV correlated with Qp/Qs determined invasively (y = 0.97, SEE = 0.23, n = 16). Thus with our method LVIV and COin can be accurately determined, and we suggest that Doppler-determined LVIV/LVOV is clinically useful for evaluating the shunt flow magnitude in VSD.

[Pulmonary to systemic flow ratios in patients with ventricular septal defect: estimation by transmitral flow velocity]

Using pulsed Doppler echocardiography, left ventricular inflow flow volume (LVIV) and outflow flow volume (LVOV) were noninvasively determined, and the ratio of pulmonary to systemic flow (Qp/Qs) was evaluated as the ratio of LVIV to LVOV (LVIV/LVOV). Thirty patients with ventricular septal defect (VSD) were studied, and 47 cardiac patients without aortic or mitral valve disease or intracardiac shunt served as controls. LVOV was derived from the left ventricular ejection flow velocity and the outflow tract diameter immediately proximal to the aortic valve ring. LVIV was derived from the transmitral flow velocity and the M-mode tracing of mitral valve motion. Doppler-determined cardiac outputs (COin and COout) were calculated as the products of LVIV or LVOV as and heart rates. Cardiac outputs were also determined by the dye dilution method (COdye) references for comparison with Doppler-determined cardiac outputs. There were good correlations between COdye and COin (y = 1.18x-243, r = 0.85, p less than 0.005, SEE = 1026 ml/min) and between COdye and COout (y = 1.16x-323, r = 0.90, p less than 0.005, SEE = 639 ml/min). LVIV and LVOV correlated well in the controls (y = 0.95x + 5.3, r = 0.94, p less than 0.005, SEE = 6.6 ml). LVIV/LVOV was 0.97 +/- 0.1 (mean +/- SD) in the controls; whereas LVIV/LVOV (1.86 +/- 0.90) was significantly higher in patients with VSD (p less than 0.01) and this ratio correlated well with Qp/Qs by an oximetry (r = 0.98, SEE = 0.20, n = 14), including patients associated with pulmonary regurgitation. These findings indicate that our method permits determination of LVIV with a high degree of accuracy and that the Doppler-determined LVIV/LVOV is clinically useful to evaluate accurately the magnitude of shunt flows in patients with VSD.