[Mitral obstruction due to infective endocarditis: a case report]

Acute valvular obstruction caused by vegetation is a rare complication infective endocarditis. To our knowledge, only 9 cases and an autopsy case by Roberts have been reported since 1967. A 46-year-old man admitted with a chief complaint of pyrexia for 2 months duration. Within 24 hours of admission, the patient noticed of increased shortness of breath. Physical examination and the chest X-ray confirmed the pulmonary edema. An echocardiogram revealed a huge echogenic mass that was adherent to the mitral leaflet and obstructed the orifice completely. Soon after the patient fell into cardiogenic shock, an emergency mitral valve replacement was undertaken. At operation, multiple verrucae arising from the entire mitral leaflet was seen to occlude the orifice. The vegetation was excised and replaced with a # 25 Omnicarbon prosthesis. Postoperatively, the patient developed multiple organ failure caused by cardiogenic and septic shock which responded well to intensive medical treatment consisting of hemodialysis and continuous arteriovenous hemofiltration. Angiographically, a mycotic aneurysm in the left radial artery was found on the 18th postoperative day. After extirpation of the infective focuses, the postoperative course had stabilized. Mitral obstruction due to infective endocarditis is a fatal disease. Prompt diagnosis with echocardiogram and an emergency surgery should be undertaken to save the patient.

Detection of host DNA sequences including the H-2 locus of the major histocompatibility complex in schistosomes

The mouse type 2 Alu (B2) sequence was detected in both DNAs of Schistosoma mansoni and S.japonicum except for the cercarial stage by the polymerase chain reaction (PCR). Using several kinds of mouse STMS (sequence tagged microsatellite site) primer sets, PCR products related to the host were found in the DNAs of S. mansoni as well as of S.japonicum. Products could be detected only in the DNA of S. japonicum using certain STMS primer sets. The fact that no products could be amplified from the DNAs of both parasites when other kinds of STMS primer sets were used suggests unequal incorporation of the host DNA into the schistosomes. Furthermore, the sequence of the N-terminal domain of H-2, the mouse major histocompatibility complex (MHC), was detected in the DNAs from S. mansoni miracidium, male adult and S. japonicum adults, whereas the sequence of the C2 domain of H-2 was found only in the DNAs of S. japonicum adults. This evidence that host DNA sequences, including the class I MHC, exist heterogeneously in the DNAs of schistosomes might provide an important insight for further understanding of host-parasite immune interactions.

Plasmodium vivax malaria infection diagnosed by indirect fluorescent antibody test

We present the diagnostically challenging case of a 51-year-old Japanese male who visited Papua New Guinea for one month. Approximately a month after returning to Japan, he experienced a high fever. Malaria was suspected and he was admitted to Tsukuba University Hospital. Although the blood smear did not reveal the malarial parasite, a diagnosis of malaria was made using an indirect fluorescent antibody test (IFAT). The patient was treated and discharged but symptoms returned three months later. This time, the blood smear was positive for malarial parasites. IFAT was useful in this case for the early diagnosis of Plasmodium vivax and for ruling out infection by Plasmodium falciparum.

Serum concentrations of apolipoproteins in patients with thyroid dysfunction

We measured serum concentrations of apolipoproteins (apo A-I, A-II, B, C-II, C-III and E) in patients with thyroid disease (hyperthyroidism; n = 44, hypothyroidism; n = 15) and in normal subjects (n = 89). We found that apoA-II, B and C-III concentrations revealed significant difference among three groups of the normal (apoA-II; 31.4 +/- 4.9 mg/dl, apoB; 85.8 +/- 16.3 mg/dl, apoCIII; 7.45 +/- 2.99 mg/dl), hyperthyroidism (apoA-II; 29.8 +/- 5.4, apoB; 63.4 +/- 18.9, apoC-III; 6.28 +/- 2.45) and hypothyroidism (apoA-II; 27.5 +/- 5.3, apoB; 108.0 +/- 30.9, apoC-III; 9.43 +/- 2.74). Thyroid hormones showed clear negative correlation to apoB (r = 0.70, p < 0.001). Furthermore, apoC-III was also found to be negatively correlated with thyroid hormone concentrations (r = 0.47, p < 0.001).

Styrene-induced hepatotoxicity in mice depleted of glutathione

In mice depleted of glutathione (GSH) by pretreatment with an inhibitor of GSH synthesis, buthionine sulfoximine (BSO; 1 hr before styrene, 2 mmol/kg or higher doses, ip), styrene (0.96-5.76 mmol/kg, po) produced hepatotoxicity characterized by an increase in serum alanine transaminase activity and cetrilobular necrosis of hepatocytes. Treatment with inhibitors of hepatic cytochrome P-450-dependent monooxygenases such as carbon disulfide, methoxsalen, piperonyl butoxide, and SKF-525A prevented or tended to reduce the hepatotoxic effect of styrene given in combination with BSO. Styrene 7,8-oxide (3.84 mmol/kg, po), a known metabolite of styrene, in combination with BSO caused an earlier and larger increase in SALT than that caused by an equimolar dose of styrene in combination with BSO. These results suggest that metabolism of styrene, possibly to styrene 7,8-oxide, is a necessary step in styrene-induced hepatotoxicity in GSH-depleted mice. Before the onset of hepatotoxicity, styrene in combination with BSO produced a larger and more prolonged depletion of hepatic GSH than that seen after the sole treatment with BSO or prolonged depletion of hepatic GSH than that seen after the sole treatment with BSO or styrene, but no depletion of hepatic protein sulfhydryls was induced by styrene in combination with BSO.

The rice culture filtrate of Bacillus cereus isolated from emetic-type food poisoning causes mitochondrial swelling in a HEp-2 cell

Rice culture filtrates of Bacillus cereus SA-50, an emetic-type strain, produced a toxin which caused cytoplasmic vacuole formation in HEp-2 and HeLa cells. Electron microscopic observation revealed that the apparent vacuoles in HEp-2 seen under a light microscope were actually swollen mitochondria. The oxygen consumption of HEp-2 cells was accelerated by the addition of the rice culture filtrate as was measured with a polarographic oxymeter; a respiratory control ratio was 1.0 for control cells, while 1.4 for ones with the filtrates. The culture filtrates showed a similar effect on the isolated mouse liver mitochondria; respiratory control ratios for the mitochondria with and without the filtrates were 3.6 and 1.0, respectively. The affecting manner of the culture filtrates on the oxygen consumption of mitochondria was similar to that of 2,4-dinitrophenol, suggesting that the culture filtrate contains a toxin acting as an uncoupler of oxidative phosphorylation in mitochondria. It is likely that the culture filtrates containing the emetic toxin of B. cereus causes mitochondrial swelling with a close relationship to the uncoupling of the oxidative phosphorylation of mitochondria.

Hepatitis C infection unrelated to blood transfusion in hemodialysis patients

Hepatitis C virus antibodies were studied using both the 1st and 2nd generation tests in 485 patients who were on maintenance hemodialysis. One hundred and eighty-seven tested positive for antibodies (38.6%); 139 of them had a history of past blood transfusion. There was a crude correlation between the amount of blood given and the antibody positivity rate among those who had a history of blood transfusion. Of 152 patients who had no blood transfusion history, 48 or 31.2% were positive for the antibodies. The length of the period during which these patients had undergone dialysis was closely correlated with the positivity rate; 50% of those who had been on dialysis for more than 10 years were positive for anti-HCV. The positivity rate among the new dialysis patients with chronic renal failure as the control was 4.6%. The difference may be accounted for by nosocomial hepatitis C virus infection. It appears that with two new needle holes made along the anastomosed blood vessels two to three times a week, the chances of patient exposure to hepatitis C virus may increase with time.

[A case of unroofed coronary sinus with persistent left superior vena cava]

A 44-year-old female with left to right shunt and persistent left superior vena cava (PLSVC) suspected of unroofed coronary sinus defect with patent right SVC and innominate vein was treated surgically. PLSVC was ligated and coronary sinus ostium was closed with a EPTFE patch. Roof defect of coronary sinus was left open and allowed the coronary venous blood to drain into the left atrium. Patient recovered well and post-operative cardiac catheterization revealed no significant right to left shunt nor desaturation of arterial blood. In the correction of unroofed coronary sinus defect and PLSVC and no other intra-cardiac defect, ligation of PLSVC and closure of coronary sinus ostium was simple and effective, although it was not anatomically corrected.

Host-related DNA sequences are localized in the body of schistosome adults

The localization of host (mouse)-related DNA sequences in the adults and cercariae of Schistosoma japonicum and S. mansoni was examined by in situ hybridization using 32P-labelled probes. The hybridization signals to the sequences of the mouse type C and type A retroviruses were clearly observed in the subtegumental layer and inner tissues of S. japonicum adults. In contrast, it was hard to find any signals to these sequences in S. mansoni adults. Distinct signals to the env-specific region of the mouse ecotropic type C retrovirus were observed in the subtegumental layer and inner tissues of S. mansoni adults. No signal to the sequence of the mouse type B retrovirus was found on the sections of either schistosome adult. The signals to the sequence of the genomic clone SmM51 derived from male S. mansoni were found in the tissues of both the schistosome adults. The signals to the sequences of the mouse type A and env-specific region of ecotropic type C retroviruses were not seen in the cercariae of each species, whereas the signals to the sequence of SmM51 were detected in S. mansoni cercariae. These observations suggest that host-related DNA sequences might be incorporated unequally into the schistosome genome during development in the final host.

[Primary chylopericardium: a case report]

A case of primary chylopericardium in a 54 year-old-man was reported. Despite 3 times of pericardiocentesis, the pericardial fluid accumulated rapidly. After the fenestration of pericardium, a small cannula was inserted for the thoracic ductgram which showed a clearly visible duct upward to the angulus venosus and an abnormal branch near the bifurcation of the trachea spilling some contrast material into the pericardial cavity. Ligation and division of the thoracic duct including an abnormal branch was performed from its entry to the thorax for a length of 13 cm upward. The postoperative course was uneventful and chest X-ray film taken 6 months after surgery showed no accumulation of chyle in the pericardium and pleural cavity.

[Assessment of left ventricular function with ESS-ESVI relationship in patients undergoing aortic valve replacement for aortic regurgitation]

Aortic valve replacement (AVR) for aortic regurgitation (AR) results in the reduction of left ventricular dimensions. But postoperative death or congestive heart failure may occur in patients with left ventricular dysfunction. Pre- and postoperative stress (ESS)-volume (ESVI) relationship by M-mode echocardiography was examined in 30 patients undergoing AVR. Postoperatively, 23 patients (Group A) achieved a normal left ventricular dimension (LVDd less than 55 mm, LVDs less than 45 mm) and 7 patients (Group B) had persistent left ventricular dilation (LVDd greater than or equal to 55 mm, LVDs greater than or equal to 45 mm). Correlation between preoperative ESS and ESVI was significant (r = 0.92, p less than 0.001), and the ESS/ESVI was greater in Group A of 1.62 +/- 0.29 kdy/cm2/ml/m2 than in Group B of 1.18 +/- 0.19 kdy/cm2/ml/m2 (p less than 0.001). Three patients with ESVI greater than 180 ml/m2 and ESS/ESVI less than 1.2 kdyn/cm2/ml/m2 died after operation. Echocardiographic variables correlated with ESS/ESVI were ESVI (r = -0.57), FS (r = -0.53) and CSA (r = -0.47). The changes in LVDs (delta Ds) after AVR correlated with ESS/ESVI in 12 patients with severe left ventricular dilatation. Postoperative left ventricular function could be predicted by ESS-ESVI relationship by preoperative DBcAMP infusion test. ESS/ESVI is sensitive to changes in the left ventricular contractility. The patients with ESVI greater than 180 ml/m2 and ESS/ESVI less than 1.2 kdyn/cm2/ml/m2 may result in poor prognostic outcome.

Improvement of ultrasonographic and serologic changes in Schistosoma japonicum-infected patients after treatment with praziquantel

We previously reported ultrasonographic and serologic abnormalities in 102 patients infected with Schistosoma japonicum in Leyte, The Philippines. These patients were subsequently treated with praziquantel (3 x 20 mg/kg), and changes in ultrasonographic images and the serum levels of liver function markers in 52 patients were followed up every three months for a period of 17 months. Improvement in the thickening of the portal vein wall and the intensity of echogenic bands was detected six months after treatment with praziquantel. The level of splenomegaly was also reduced in 42 patients who originally did not show the production of collateral vessels. A significant decrease in the serum total bile acid (TBA) level was detected in all patients six months after treatment with praziquantel. However, significant ultrasonographic changes could not be detected in the patients classified as type 3, with severe hepatic fibrosis caused by the long-term infection. These results clearly show that ultrasonographic examination, along with data on the serum TBA level, provides a sensitive tool to monitor the severity of hepatic fibrosis and portal hypertension caused by S. japonicum infection, as well as the improvement resulting from praziquantel treatment.

Ultrasonographic and serologic abnormalities in Schistosoma japonicum infection in Leyte, the Philippines

We have identified specific ultrasonographic changes in Schistosoma japonicum-infected patients associated with serologic indicators of general liver function. An ultrasonographic examination concomitant with hematologic and biochemical serum analyses was performed on 102 patients at the Schistosomiasis Hospital in Leyte, The Philippines. The ultrasonographic liver images were classified into four patterns, according to the development of periportal fibrosis and the patterns of echogenic bands. Eleven cases with a long-term infection showed typical septal formation (network pattern). Other ultrasonographic changes in the portal system, such as the severity of splenomegaly, did not correlate with the age of the study patients or the duration of their infection; however, the production of collateral vessels was clear in the group of older patients. Among various hematologic and biochemical serum indicators of liver damage, the serum levels of total bile acid (TBA) and procollagen-III-peptide (P-III-P) strongly correlated with the development of hepatic fibrosis and protal hypertension. These findings suggest that the ultrasonographic liver patterns classified here, along with the changes in serum levels of TBA and P-III-P, provide useful indicators for field monitoring of S. japonicum infection.

Serologic and ultrasonographic parameters of praziquantel treatment of hepatic fibrosis in Schistosoma japonicum infection

We describe the parameters useful in evaluating the development of hepatic fibrosis in Schistosoma japonicum infection, as well as its improvement after treatment with praziquantel (PZQ). Various serologic parameters and ultrasonographic images were examined, and their changes were monitored using rabbits infected with 200 or 300 cercariae of S. japonicum. Infected rabbits were administered one oral treatment of PZQ at a dosage of 100 mg/kg at 6, 12, or 24 weeks after infection. Histopathologic examinations revealed that PZQ had a strong and rapid effect, even on damage that developed long after the infection. The improvement of moderate hepatic fibrosis that developed over 24 weeks after infection was also detected by histopathologic examinations. The serum level of total bile acid was the most sensitive parameter in evaluating the severity of hepatic fibrosis and its improvement after treatment with PZQ. The level of serum procollagen-III-peptide was also useful in evaluating the development of hepatic fibrosis, but not in its improvement. Ultrasonography revealed specific echogenic bands and nodules according to the progress of granuloma formation and fibrosis, and the reversal of these changes could also be observed after treatment with PZQ.

[Interposition graft technique for the treatment of AAE (annuloaortic ectasia) with aortic regurgitation: surgical results]

Interposition graft technique had been used exclusively in 8 consecutive patients with AAE and AR. Two patients with severely dilated left ventricle (CTR 65, 80%, LVDd 93, 83 mm, LVDs 86, 68 mm), and 1 patient complicated with the postoperative mediastinitis died in the perioperative period, 10, 145 and 135 days after surgery, respectively. In the remaining 5 patients, excellent clinical improvement was observed with the reduction of CTR and echo-cardiographic findings without formation of hematoma, pseudoaneurysm, and leak from the suture lines on DSA and CT.

Existence of host-related DNA sequences in the schistosome genome

DNA sequences homologous to the mouse intracisternal A particle and endogenous type C retrovirus were detected in the DNAs of Schistosoma japonicum adults and S. mansoni eggs. Furthermore, other kinds of repetitive sequences in the host genome such as mouse type 1 Alu sequence (B1), mouse type 2 Alu sequence (B2) and mo-2 sequence, a mouse mini-satellite, were also detected in the DNAs from adults and eggs of S. japonicum and eggs of S. mansoni. Almost all of the sequences described above were absent in the DNAs of S. mansoni adults. The DNA fingerprints of schistosomes, using the mo-2 sequence, were indistinguishable from each other and resembled those of their murine hosts. Moreover, the mo-2 sequence was hypermethylated in the DNAs of schistosomes and its amount was variable in them. These facts indicate that host-related sequences are actually present in schistosomes and that the mo-2 repetitive sequence exists probably in extra-chromosome.

[Familial cardiac myxoma with multiple and contralateral recurrence]

This report described a familial recurrent cardiac myxoma involving mother and daughter. The mother, at 27 year of age, had developed recurrent multiple myxomas in both left and right atrium and right ventricle 4 years after surgical excision of left atrial myxoma. Excision was successful and remains well without signs of recurrence 9 years postoperatively. In an asymptomatic 13-year-old daughter, a recurrent left atrial myxoma was found 3 years after the excision of right atrial myxoma by echocardiographic follow-up at 6 month intervals. Excision of left atrial myxoma was performed and histology showed the essentially the same findings as primary myxoma without signs of malignancy. From an experience of this familial recurrent myxoma and a review of 38 cases of 17 familial cardiac myxoma, it is recommended that wide excision of tumor including surrounding tissues, thorough search for multiple heterotopic tumors at surgery, close postoperative echocardiographic follow-up for at least 5 years, and examination of skin and breast tumor, and endocrine disorder for "complex" myxoma.

Elevation of the petrous bone caused by hyperplasia of the occipital bone presenting as hemifacial spasm: diagnostic values of magnetic resonance imaging and three-dimensional computed tomographic images in a bone anomaly

A case of elevation of the petrous bone due to hyperplasia of the occipital bone presenting as hemifacial spasm is reported. A 44-year-old man sought treatment for twitching of the buccal muscles on the right side that progressed rapidly in severity within 2 weeks of the onset. The anatomical details of the petrous and occipital bones were delineated clearly by computed tomographic scans of a bone window level. Details of the brain stem were shown by magnetic resonance images. The bone anomaly was displayed more realistically by three-dimensional computed tomographic reconstructions. The faithful representation of structures with these radiological studies should be mandatory, to prepare the surgical planning of such a complicated bone anomaly.

[Reconstruction of radicular arteries in the total replacement of thoracoabdominal aorta]

A technique of reconstructing low intercostal, high lumbar arteries and Adamkiewicz artery is described to prevent paraplegia following operations on the thoracoabdominal aorta. A graft with a side branch is anastomosed proximally and a side branch to the distal thoracic aorta after reinforcement of the stumps under the partial bypass. Applying a clamp on the main graft, flow through the side branch and true lumen of the aneurysm is reestablished and bypass is terminated. The main graft, extended with a Y-graft, is anastomosed to common iliac arteries after proximal suture-ligation to perfuse the lower extremities. Splanchnic arteries are reconstructed according to DeBakey's technique which is followed by trimming of the thoracoabdominal aorta incising longitudinally with a clamp applied on the 1st side branch. Edges of the trimmed aneurysm are sutured to the slit of the graft from the right common iliac artery reconstructing intercostal, lumbar arteries and Adamkiewicz artery from the level of L2 upwards to T4 or more. As a final step, the graft is sutured to the 1st side branch allowing perfusion distally to the right lower extremity and the main graft to the splanchnic arteries and left lower extremity after division of a Y-graft right branch. The technique minimizes ischemic time for reconstruction of the aortic branches and enables complete reconstruction of the radicular arteries.

[Two cases of perioperative coronary vasospasm following ASD closure and OMC]

Two cases of perioperative coronary spasm following ASD closure and OMC are reported. A 36-year-old female had been diagnosed of vasospastic angina and another 47-year-old female patient was diagnosed of effort angina for 99% stenosis of the right ventricular branch preoperatively. Both patients suffered from coronary vasospastic attack and ventricular fibrillation several times within 17 hours postoperatively. Although the coronary dissolution was obtained finally following aggressive cardiac massage, administration of spasmolytic agents, such as NTG, lidocaine, DBcAMP and the start of IABP, the resolution was stormy due to the hemodynamic derangement. To prevent the coronary spastic episode, it is suggested, for patients of possible coronary spasm, to avoid arousal stimulation and to administer spasmolytic agents prophylactically within the first postoperative day.

[Left ventricular-right atrial communication following mitral valve replacement]

A case of an acquired left ventricular-right atrial communication complicating Omnicarbon replacement of a severe calcified mitral valve in the area of the posteromedial commissure is reported. The intricate relationships of the membranous atrioventricular septum to the mitral valve and the tricuspid valve predispose to the creation of an iatrogenic left ventricular-right atrial fistula when aggressive debridement of extensive valvular calcification is performed. Emphasis is placed on the diagnosis, and immediate surgical repair is advocated as soon as this complication is discovered.

[Effect of ulinastatin (UL) on renal function and lactic acidosis during open-heart surgery: comparison with aprotinin (Ap)]

Comparison was made on the renal function and lactic acidosis during cardiopulmonary bypass (CPB) between the group Ul (n = 15) and group Ap (n = 27). A 300,000 u, of ulinastatin was administered intravenously before CPB and 300,000 u, in the prime solution. A 300,000 u, of aprotinin was administered in the prime solution. Urine output during CPB was not significantly different, but the total dose of furosemide administered was less in group Ul and a significant difference (p less than 0.05) was observed in the free water clearance at CPB 1 hr. and 3 hr. postoperatively, -0.83 +/- 0.16 and -1.74 +/- 0.14 in group Ul and -0.43 +/- 0.10, -0.99 +/- 0.14 in group Ap, respectively. Arterial lactate increased as the perfusion time increased but the level at the end of CPB was significantly lower (p less than 0.05) in group Ul and the added 7% NaHCO3 to correct metabolic acidosis during CPB of 29.3 +/- 9.5 ml in group Ul was less than in group Ap of 82.2 +/- 15.2 ml (p less than 0.01). The result suggests the favourable effects of ulinastatin on the renal function and lactic acidosis during CPB.

[Left coronary ostial stenosis in aortitis syndrome--patch mounted graft technique for proximal anastomosis]

Late restenosis or total occlusion of proximal aortic anastomosis frequently occurs due to intimal proliferation in aortitis CABG patients although successful early postoperatively. A Gore-Tex patch (diameter 20 mm) mounted grafts to LAD and CX with a single ostium was sutured in the inflammatory aorta to prevent late occlusion in a 40-year-old female patient. Postoperative CAG a month after showed a patent graft to LAD and improved exercise treadmill test. Graft to Cx occluded due to competed flow from LAD. No aneurysm was found in the proximal anastomosis. Tissue nonpermeable Gore-Tex mounted graft is considered to be suitable for CABG in aortitis patients with the high incidence of late occlusion.