Novel inactivating missense mutations in the thyrotropin receptor gene in Japanese children with resistance to thyrotropin

We describe Japanese siblings with resistance to thyrotropin (TSH) who are compound heterozygotes for two novel mutations in the TSH receptor gene. The affected siblings had increased serum TSH, normal serum thyroid hormones, and normal positioned but slightly hypoplastic thyroid glands. The mutated paternal allele has the substitution of His (CAC) in place of Arg (CGC) at codon 450 (R450H) of the TSH receptor. The mutated maternal allele has the substitution of Ser (AGT) in place of Gly (GGT) at codon 498 (G498S) of the TSH receptor. COS-7 cells transfected with the R450H mutant exhibited a slightly decreased TSH binding and a slightly decreased cyclic adenosine monophosphate (cAMP) response to TSH, whereas cells transfected with the G498S mutant exhibited a markedly decreased TSH binding and a markedly decreased cAMP response to TSH. Flow immunocytofluorometry analysis demonstrated that the G498S mutant resulted in extremely low expression at the cell surface as compared with the wild type receptor and the R450H mutant, in spite of a normal intracellular synthesis. The present cases are the first Japanese patients with TSH resistance in whom mutations in the TSH receptor gene have been identified. These novel mutations may contribute to understanding of the struc-ture-function relationship of the TSH receptor.

Quantitative ultrasound as a predictor of node metastases and prognosis in patients with breast cancer

BACKGROUND

A retrospective study was performed to determine whether preoperative quantitative ultrasound assessment could predict axillary lymph node metastases and prognosis in patients with breast cancer. We focused on the presence of a halo, which is one of the features of breast cancer on ultrasound and represents reflections from the invading margin around infiltrating malignancies.

METHODS

We evaluated ultrasonography from 187 infiltrating breast carcinoma patients with tumors 5 cm or less in greatest dimension (T1, T2). Using computer image analysis, the halo area (H) and the sum of the area of halo and internal echo (total tumor area (T)) were measured, and the ratio of halo to entire tumor (H/T, halo ratio) was calculated and compared with lymph node status and prognosis.

RESULTS

The mean of the halo ratio was 0.38+/-0.13. Using the value of 0.42 as a cut-off, the high halo ratio group had significantly worse prognoses for both overall and disease-free survival at 49 months in median follow-up (p <0.001 and p <0.0005, respectively). The specificity of a high halo ratio in the T1 classification for predicting axillary node metastasis was 83.1%, with a negative predictive value of 86.8%. In patients with tumors 1.0 cm or smaller, the negative predictive value was 100%. In a multivariate analysis, halo ratio was an independent predictor of disease-free survival of breast carcinoma patients (p =0.0232).

CONCLUSIONS

Preoperative quantitative ultrasound may be a useful non-invasive method for predicting the presence of axillary lymph node metastases and prognosis in patients with primary breast cancer.

The effects of the Na(+)/Ca(++) exchange blocker on osmotic blood-brain barrier disruption

Osmotic disruption of the blood-brain barrier (BBB) by mannitol is currently being used to enhance drug delivery in human brains. Despite clinical and experimental interest, to date the time course in the early phase of disruption has not been accurately identified. The mechanism in barrier closure also remains elusive. We first studied the rapid change in cerebrovascular permeability after BBB disruption in rats, and then demonstrated that the Na(+)/Ca(++) exchange blocker (KB-R7943) prolongs osmotic disruption. Osmotic BBB disruption was attained by using intra-arterial infusion of hypertonic mannitol in Sprague-Dawley (SD) rats. To measure the changes in cerebrovascular permeability, perfusate containing [14C]-sucrose was infused intra-arterially at different time points following osmotic stress. Cerebrovascular permeability was then measured with the in situ brain perfusion technique. This is the first in vivo study demonstrating that osmotic disruption is prolonged by the Na(+)/Ca(++) exchange blocker, which did not affect the peak level of BBB disruption. The exact time course of cerebrovascular reversibility was studied and the earliest BBB disruption was seen to occur 5 min after osmotic stress. Histopathological examination after osmotic disruption with the Na(+)/Ca(++) exchange blocker showed no neuronal damage in rat brains. Our findings represent important experimental information regarding pharmacological manipulation of BBB disruption. The possibility of prolonging the transient opening of the BBB has major clinical implications.

Antineutrophil cytoplasmic autoantibody specific for proteinase 3 in a patient with shunt nephritis induced by Gemella morbillorum

A 17-year-old girl had been placed with ventriculoperitoneal, then ventriculoatrial shunts for congenital hydrocephalus since birth. The patient originally was diagnosed as having a lupus-like disease, but later turned out to have shunt nephritis, presenting with fever, proteinuria, pancytopenia, and hypocomplementemia. Antineutrophil cytoplasmic autoantibody specific for proteinase 3 (PR3-ANCA) was detected in her serum. The patient received oral prednisolone and repeated methylprednisolone pulses, with essentially no beneficial effects. A gram-positive coccus, Gemella morbillorum, was recovered from her blood as well as cerebrospinal fluid, and the culture of the shunt catheter established the diagnosis of shunt nephritis. Removal of the shunt catheter improved symptoms dramatically and decreased PR3-ANCA in serum to an undetectable level. Because steroids had no effects and the control of bacterial infection lowered PR3-ANCA levels, the antibody would have been induced by continuous infection with G morbillorum.

Treatment of tuberculum sellae meningiomas:a long-term follow-up study

Surgical techniques and their results for tuberculum sellae meningiomas were studied. Thirty-three cases, the first of which was operated in 1980, were analysed. There were 4 men and 29 women with an average age of 46.7 years. Eight cases underwent reoperations. The mean follow-up was 10.7 years. Approaches were pterional for 15 patients, FOZ/FO for 10, bilateral subfrontal for 6, and others for 2. Simpson's grade (I, II, III, IV) were 12, 9, 0, and 12 cases respectively. Recurrence rate was 0% for grade I and 58.3% for grade IV. The FOZ/FO approach resulted in a lower Simpson's grade (P=0.05), but other factors were not related to Simpson's grade (P=0.05). The postoperative visual outcome did not depend on total (grade I and II) or subtotal (grade III and IV) removal (P=0.01). We conclude that radical removal of the tumours may result in lower recurrence rate without increasing surgical complications. Furthermore, skull base approaches can improve the rate of radical removal of tuberculum sellae meningiomas.

Colon cancer with meningeal carcinomatosis and myelodysplastic syndrome in a patient who underwent intensive chemotherapy for acute myelogenous leukemia: a case report

A 59-year-old man was admitted to our hospital because of disturbance of consciousness and hyponatremia. The patient had suffered from acute myelogenous leukemia (AML) with 46,XY and received chemotherapy for 5 years. Meningeal carcinomatosis was diagnosed due to the detection of carcinoma cells in the cerebrospinal fluid (CSF). Hyponatremia was caused by syndrome of inappropriate secretion of anti-diuretic hormone (SIADH). Bone marrow examination revealed myelodysplastic syndrome (MDS) with deletion of the long arm of chromosome 7. Emergence of a new abnormal clone was suggested. The patient died from brain herniation. Post mortem examination showed adenocarcinoma in the colon. An association between chemotherapy and both colon cancer and MDS was suggested.

Histopathological analyses of silent pituitary somatotroph adenomas using immunohistochemistry, in situ hybridization and confocal laser scanning microscopic observation

To characterize the morphological and functional aspects of silent somatotroph adenomas with paradoxical responses of GH in TRH or GnRH provocation tests, which are considered to be a useful strategy for endocrinological identification of silent somatotroph adenomas, we examined three silent somatotroph adenomas histopathologically. The adenomas were investigated by immunohistochemistry, including the highly sensitive catalyzed signal amplification system, the non-radioisotopic in situ hybridization method, and confocal laser scanning microscopy. GH production and GH-immunopositive secretory granules in the adenoma cells were demonstrated histopathologically, and the adenomas were interpreted as being densely granulated somatotroph adenomas. Endocrinological identification of silent somatotroph adenomas in combination with paradoxical responses of GH in TRH or GnRH provocation tests may elucidate the increasing number of silent somatotroph adenomas that have been regarded as mammotroph or clinically inactive adenomas. One should be aware of the differences between the previously reported silent somatotroph adenomas, most of which are sparsely granulated somatotroph adenomas, a somatotroph adenomas with paradoxical and the silent somatotroph adenomas, most of which are sparsely granulated somatotroph adenomas, and the silent somatotroph adenomas with paradoxical responses of GH in TRH or GnRH provocation tests, which are densely granulated somatotroph adenomas.

The posterior inferior cerebellar artery arising from the extracranial segment of the internal carotid artery via the hypoglossal canal without an interposed segment of the basilar artery: a persistent primitive hypoglossal artery variant

The authors present a rare case of a persistent primitive hypoglossal artery (PHA) variant ending in the posterior inferior cerebellar artery (PICA) without an interposed segment of the basilar artery and describe briefly the possible embryogenesis of this anomaly.

Surgical approaches and strategies for skull base chordomas

Object

The management of chordomas involving the skull base continues to present a number of treatment-related problems. Recently, both radical resection and charged-particle irradiation or stereotactic radiosurgery have reportedly been found effective for tumor control and for promoting a better quality of life in patients. In this article the authors analyzed the outcomes in 17 patients with skull base chordomas who were surgically treated at Kobe University Hospital between 1972 and 2000.

Methods

Preoperative radiological examinations included magnetic resonance imaging, computerized tomography, angiography, and balloon occlusion test of the internal carotid artery. Among the various surgical approaches used to remove the tumor were the frontoorbitozygomatic, transmaxillary, transcondylar, transsphenoidal, and the transbasal. Total removal was achieved in two (12%), near-total removal in three (18%), subtotal removal in nine (52%), and partial removal in three patients (18%). Since 1990, chordomas have been radically resected via various skull base approaches; the combined total or near-total removal rate has been 80% in this period. Radical removal of the tumors has not led to an increased risk. At the final follow-up review (mean 59.5 month), 75% of the patients were still alive, and 25% had died of chordoma recurrence. The overall recurrence-free survival rate was 82% at 3 years and 51% at 5 years. The 5-year recurrence-free survival rate in the five patients who underwent the operation during the past decade was 77% (mean follow up of 5.2 years). In two patients with recurrent tumors who underwent radiosurgery, no evidence of tumor regrowth was demonstrated at 3 years posttreatment.

Conclusions

The authors suggest that for the treatment of skull base chordomas radical resection is a key factor for longer survival and improved quality of life. Patients with sufficiently small tumors, which show a favorable configuration and location, can be suitable candidates for stereotactic radiosurgery.

Preliminary individual adjuvant therapy for gliomas based on the results of molecular biological analyses for drug-resistance genes

New adjuvant therapy individualized by the results of reverse transcription-polymerase chain reaction (RT-PCR) for drug-resistance genes has been used to treat malignant gliomas. Protocol studies for malignant gliomas were not so encouraging in their therapeutic results because of heterogeneity and the various drug-sensitivities of the tumors. Individualization of glioma therapy is recommended. Drug-resistance genes messenger ribonucleic acid (mRNA) expressions were investigated in drug-resistant human glioma cell lines derived from U87MG and 46 frozen samples of retrospectively examined neuroepithelial tumors (12 low grade neuroepithelial tumors, 16 Grade III gliomas, 11 glioblastomas, and 7 other malignant neuroepithelial tumors such as medulloblastomas and primitive neuroectodermal tumors) by RT-PCR with the specific primers for O6-methylguanine DNA methyltransferase (MGMT), multidrug-resistance gene 1 (MDR1), multidrug-resistance-associated protein (MRP), and glutathione-S-transferase-pi (GST-pi). Thirty-seven preliminary individual adjuvant therapies (IAT) based on RT-PCR results, mainly in MGMT expression, were performed on 30 consecutive patients with neuroepithelial tumors. In the retrospectively examined series, the initial response to 1-(4-amino-2-methyl-5-pyrimidynyl) methyl-3-(2-chloroethyl)-3-nitrosourea hydrochloride (ACNU) was correlated most significantly to the MGMT mRNA expression among 11 independent prognostic factors (p = 0.0037) in multivariate logistic regression analysis. In the preliminary IAT, 17 of 32 evaluable therapies had a partial or complete response (53.1% response rate). Our IAT based on RT-PCR seemed to be more effective than conventional therapies for malignant gliomas.

Identification of a silent pituitary somatotropic adenoma based on a paradoxic response of growth hormone on a thyrotropin-releasing hormone or gonadotropin-releasing hormone provocation test

Preoperative endocrinologic identification and surgical removal of a silent somatotropic adenoma among patients with either amenorrhea or galactorrhea, or both, are beneficial for the restoration of menstruation and ovulation. Paradoxic rises of serum growth hormone in either a thyrotropin-releasing hormone or a gonadotropin-releasing hormone provocation test and high serum growth hormone levels were noted in the 3 patients with a silent somatotropic adenoma.

Pelvic arteriovenous malformation with iliac vein thrombosis. A case report

BACKGROUND

Congenital arteriovenous malformations (AVMs) of the pelvis are relatively rare and are difficult to treat because of diffuse extension and the number of feeding vessels.

METHODS

We describe a patient with a pelvic AVM with shunts who also developed iliac vein thrombosis. The AVM was diagnosed during evaluation of what had initially appeared to be a venous stasis ulcer.

RESULTS

The ulcer was successfully treated by Palma s procedure, partial resection of the feeding vessels, and transcatheter arterial embolization.

CONCLUSIONS

Coexistence of a pelvic AVM with an iliac vein thrombosis has not previously been reported.

Evaluation of waste pyrolysis characteristics in a pressurized fluidized bed reactor

To obtain the distribution of fuel components to gas, tar and char in a pressurized fluidized bed waste pyrolyzer, experiments were conducted with a laboratory scale fluidized bed reactor. Waste samples were fed batchwise from the top of the reactor into the fluidized bed of silica sand and pyrolyzed by nitrogen/nitrogen-O2 gas and the effects of pressure, particle size, heating rate and oxygen addition were investigated. In the case of rubber, the char yield tended to increase a little and the tar yield decrease over the pressure of 304-709 kPa. In comparison with the thermogravimetry data it was clearly demonstrated that the char yield from fluidized bed pyrolysis is much lower. A small amount of oxygen addition decreased both tar and char yields but its further increase did not affect them very much.

Cerebral vasculitis in chronic mucocutaneous candidiasis: autopsy case report

An autopsy case of chronic mucocutaneous candidiasis (CMCC) is reported here, in which cerebral vasculitis developed in the final stage. A 32-year-old man who had suffered from superficial candidial infection since his childhood was diagnosed as having CMCC. During the past 7 years the patient had developed various associated disorders including insulin-dependent diabetes mellitus (IDDM), common variable immunodeficiency (CVID), candidial esophagitis, multiple digestive tract ulcers and pyothorax. In 1998, at the age of 32, he developed convulsions that were accompanied by impairment of consciousness, and which were temporarily treated with steroid pulsed-medication. Epileptic status associated with widespread cerebral infarctions occurred subsequently, however, and the patient died of sepsis 2 months later. At autopsy, multiple cerebral infarctions and arterial thrombosis were evident. These were histologically proven to be primary vasculitis which was confined solely to the brain, and this was verified by general pathological examination. Thus, some as yet unknown cerebrovascular factors might be involved in the onset of an autoimmune-related vasculitis in patients with a longstanding immunodeficiency state such as CMCC.

Spontaneous peritumoral haemorrhage associated with sinus confluence meningioma: case report

BACKGROUND

Torcular or sinus confluence meningioma is rare and surgically formidable. This reported sinus confluence meningioma was associated with peritumoral intracerebral hemorrhage. The surgical strategy and the mechanism of peritumoral hemorrhage are discussed.

CASE DESCRIPTION

A 42-year-old woman presented with a history of headache, vomiting, and cerebellar dysfunction for 2 months. Plain computed tomography (CT) scan and magnetic resonance imaging (MRI) demonstrated a high-density mass in the torcular region involving both lateral sinuses. MR angiography demonstrated complete occlusion of the left lateral sinus and straight sinus and stenosis of the right lateral sinus. Two years after her first operation she experienced sudden headache and left upper quadrant hemianopsia. Plain CT scan and MRI showed a hyperintense tumor in the torcular region with an intracerebral hematoma in the right occipital lobe. An angiogram demonstrated occlusion of the caudal part of the superior sagittal sinus, bilateral transverse sinuses, and straight sinus. Gross total removal of the tumor was done along with the left lateral sinus through a suboccipital and a supratentorial occipital craniotomy in the first operation. The patient underwent total resection of the tumor at second operation through a bilateral occipital and suboccipital craniotomy along with resection of the dura including the confluence, the caudal part of the superior sagittal sinus, the right lateral sinus, and the straight sinus. The postoperative course was uneventful and postoperative MRI showed total removal of the tumor.

CONCLUSION

Sinus confluence meningioma may present with peritumoral hemorrhage. Radical removal may be possible when the sinus confluence is completely occluded and there is good collateral drainage.

Spontaneous intracranial hypotension associated with bilateral chronic subdural hematomas--case report

A 34-year-old female presented with spontaneous intracranial hypotension (SIH) manifesting as severe postural headache and meningism. Magnetic resonance (MR) imaging with gadolinium showed diffuse pachymeningeal enhancement. She developed bilateral chronic subdural hematomas 4 weeks after the onset of the symptoms. MR imaging showed descent of the midline structures of the brain. The bilateral chronic subdural hematomas were surgically drained, with no remarkable pressure. Postoperative MR imaging showed complete resolution of the pachymeningeal enhancement and relevation of the midline structures of the brain. SIH is an uncommon and probably unrecognized condition because of the usually benign course. However, this case emphasizes that SIH is not entirely benign. SIH should be considered if there is no identifiable risk for intracranial hemorrhage, particularly in young patients. Neurosurgical intervention for the treatment of the underlying cerebrospinal fluid leak may be required if SIH persists.

Growth hormone-releasing hormone expression in pituitary somatotroph adenomas, studied by immunohistochemistry and in situ hybridization using catalyzed signal amplification system

Growth hormone-releasing hormone (GHRH) is a well-known hypothalamic hormone that stimulates the synthesis and release of growth hormone (GH) as well as the proliferation of GH-producing cells in the anterior pituitary gland. Recent reports have shown GHRH synthesis in pituitary somatotroph adenomas, but GHRH immunoreactivity has not been shown in previous studies. To confirm the role of locally generated GHRH for the progression of somatotroph adenomas, we investigated the expression of GHRH in 25 pituitary somatotroph adenomas immunohistochemically, through the use of both conventional avidin-biotin-complex (ABC) method and novel catalyzed signal amplified (CSA) system. In addition, we investigated the expression of GHRH mRNA and GHRH receptor mRNA with in situ hybridization (ISH) using the CSA system. The weak immunopositivity of GHRH was observed in only 2 adenomas (8.0%) of 25 somatotroph adenomas using the ABC method. In contrast, 15 adenomas (60.0%) of 25 somatotroph adenomas were immunopositive for GHRH, as shown by CSA system. Very few of nonsomatotroph adenomas were immunopositive for GHRH using the CSA system. The expression of GHRH mRNA was confirmed, using the CSA-ISH system in 13 adenomas (72.2%) of 18 somatotroph adenomas. In 11 adenomas (61.1%) of 18 somatotrophic adenomas, the expression of GHRH receptor mRNA was demonstrated using the CSA-ISH system. This is a first report that clarified histopathologically GHRH production in pituitary somatotrophic adenomas. The demonstration of GHRH and its receptor expression is meaningful in clarifying the autocrine or paracrine regulation of GHRH in GH production and progression of pituitary somatotroph adenomas.

Age-related increases in plasma phosphatidylcholine hydroperoxide concentrations in control subjects and patients with hyperlipidemia

BACKGROUND

The basal lipid peroxide concentration in the plasma of patients with hyperlipidemia may be related to atherosclerosis. Quantitative determination of lipid peroxides in the plasma is an important step in the overall evaluation of the biochemical processes leading to oxidative injury. Unfortunately, the currently available methods for lipid peroxidation lack specificity and sensitivity.

METHODS

Hyperlipidemic patients (44 males and 50 females), ages 12-82 years (mean +/- SE, 53 +/- 2.3 years for males, 58 +/- 2.0 years for females, and 56 +/- 14 years for total cases), and normolipidemic volunteers (controls, 32 males and 15 females), ages 13-90 years (49 +/- 4 years for males, 65 +/- 4 years for females, and 55 +/- 24 years for total cases), were recruited in the present study. Plasma phosphatidylcholine hydroperoxide (PCOOH) was determined by chemiluminescence-HPLC (CL-HPLC).

RESULTS

Plasma PCOOH concentrations increased with age in both controls and hyperlipidemic patients. However, the mean plasma PCOOH concentration in patients with hyperlipidemia (331 +/- 19 nmol/L; n = 94) was significantly (P <0.001) higher than in the controls (160 +/- 65 nmol/L; n = 47). Plasma PCOOH concentrations were similar in three hyperlipidemic phenotypes: hypercholesterolemia (IIa), hypertriglyceridemia (IV), and combined hyperlipidemia (IIb). The mean plasma PCOOH in patients with treatment-induced normalized plasma lipids was 202 +/- 17 nmol/L. There was no significant correlation between plasma PCOOH concentration and total cholesterol, triglycerides, or phospholipids in hyperlipidemic patients. For all subjects, there was a significantly positive correlation between plasma PCOOH and each lipid (total cholesterol, P = 0.0002; triglycerides, P = 0.0137; and phospholipids, P <0.0001). Analysis of fatty acids composition of plasma phosphatidylcholine showed significantly low concentrations of n-6 fatty acids moieties (linoleic acid and arachidonic acid) in patients compared with controls.

CONCLUSIONS

Our results suggest that an increase in plasma PCOOH in patients with hyperlipidemia may be related to the development and progression of atherosclerosis, particularly in the elderly. Measurement of plasma PCOOH is useful for in vivo evaluation of oxidative stress.

Long-term results of facial nerve function after acoustic neuroma surgery--clinical benefit of intraoperative facial nerve monitoring

The goals in acoustic neuroma surgery should be the total removal of tumor and preservation of facial nerve function. The aim of this study is to establish the benefit of intraoperative monitoring for the total removal of tumor and the long-term result of facial nerve function after surgery. Thirty-two patients, who were operated on between 1985 and 1995, were divided into two groups: an unmonitored (n = 14) and a monitored (n = 18) group. Postoperative facial nerve function was followed by a modified House-Brackmann grading (H&B) immediately (initial), and at 1 week, 1 month, 6 months and 1 year (final) after surgery. A final H&B grade of I/II was taken as the preservation of facial nerve function. Facial nerves were preserved anatomically in all cases. A total tumor removal was accomplished in 21% of unmonitored group and in 72% of monitored group patients. Final H&B (I/II) was achieved in 36% of unmonitored group and in 83% of monitored group patients. All 9 patients with initial H&B (I/II) had final H&B (I/II). None of 5 patients with initial H&B (V/VI) had final H&B (I/II). However, 3 patients showed late-recovery of facial weakness at 6 months after surgery. Eighteen patients with initial H&B (III/IV) had various degrees of final facial weakness. Among them, 12 patients showed early-recovery at 1 month after surgery. In conclusion, facial nerve monitoring during acoustic neuroma surgery is useful to improve the rates of total removal of tumor and functional preservation of facial nerve. We can expect final degrees of facial weakness by initial degrees in conjunction with sequential changes in postoperative facial weakness.

[Rapidly progressed secondary amyloidosis in a patient with Still's disease with gamma-allele in his SAA 1 gene]

A fifteen-year-old boy was admitted to our hospital because of lower abdominal pain, watery diarrhea and mucobloody stool. Two years before admission, he was diagnosed to have Still's disease presenting with polyarthritis, sore throat, remittent fever and typical skin rash. He had been treated with non-steroidal anti-inflammatory agents, oral prednisolone and low-dose methotrexate. Although he was almost free of symptoms during the next two years, serum C-reactive protein (CRP) levels continued to be elevated moderately. He began to complain of lower abdominal pain and loose stool in May 1997 and came down with mucous-bloody diarrhea in June. Laboratory data on admission showed an elevated level of serum CRP (13.9 mg/dl). The biopsy of the stomach, ileum, sigmoid colon and rectum revealed the deposition of amyloid protein of AA type, which confirmed the diagnosis of secondary amyloidosis. The dose of prednisolone was increased and dimethyl sulfoxide per os or rectum was instituted, which improved his gastro-intestinal symptoms to some extent. However, fever, arthritis and diarrhea recurred along with tapered prednisolone dosage. In addition to gastro-intestinal symptoms, arrhythmia and proteinuria appeared. These symptoms were considered to reflect general deposition of amyloid in his body. He is now on immunosuppressive agent and high-dose prednisolone. Several studies report the higher frequency of gamma-allele of SAA 1 gene in the cases of rheumatoid arthritis with AA-amyloidosis than in those without. In the patient presented here, molecular biological analysis revealed that his SAA 1 gene was composed of beta- and gamma-allele. The presence of gamma-allele in his SAA 1 gene might be one of the factors that predisposed him for generalized deposition of amyloid protein in such a short period of time.