Relapse of aseptic meningitis induced by ipilimumab and nivolumab therapy for metastatic renal cell carcinoma: A case report

The combined immunotherapy of nivolumab and ipilimumab causes a variety of autoimmune-related adverse events (irAEs). The current report details a 70-year-old woman with clear cell renal cell carcinoma metastasis in the lung. Two weeks after two courses of treatment, the patient complained of headache, dizziness and nausea. Cerebrospinal fluid (CSF) analysis revealed an elevated protein level of 195 mg/dl and a significantly elevated white blood cell (WBC) count of 830/mm³ (lymphocytes, 825/mm³; neutrophils, 5/mm³). The results excluded malignancy and infection. The patient was diagnosed with aseptic meningitis and was administered intravenous prednisolone (1 mg/kg/day). On the 49th day of the 2nd course of treatment, no recurrence of clinical symptoms was exhibited during maintenance oral steroid treatment (prednisolone 10 mg/day) and CSF analysis revealed that the WBC count had dropped to 44/mm³ (lymphocytes only). Therefore, the 3rd course of treatment was readministered the next day. After two weeks, the patients again complained of nausea, anorexia and fatigue. CSF analysis demonstrated that the WBC count was not increased from the result obtained previously. However, brain MRI scans revealed the mild diffuse enlargement of the pituitary and endocrine system tests revealed reduced adrenocorticotropic hormone (ACTH; 2.0 pg/ml) and cortisol (1.12 µg/dl) levels. The patient was diagnosed with isolated ACTH deficiency and oral hydrocortisone was administered after prednisolone cessation. On the 25th day of the 3rd course of treatment, the patient complained of headache and anorexia. CSF examination revealed that the WBC count had increased a second time (53/mm³; lymphocytes only) and laboratory data revealed hepatic dysfunction. The patient was then diagnosed with relapse of aseptic meningitis and liver dysfunction. While continuing oral hydrocortisone treatment, the administration of intravenous prednisolone was started. The observed liver dysfunction and aseptic meningitis gradually improved. The current report may be useful for avoiding delays in the diagnosis and treatment of this life-threatening and uncommon irAE, in which CSF examinations are useful for diagnosis and management.

P832LDL-C levels on statins and cardiovascular event risk in stable coronary artery disease: An observation from the REAL-CAD study

Background

The relation between very low on-treatment low-density lipoprotein cholesterol (LDL-C) level and the cardiovascular event risk is still unclear in patients receiving the same doses of statins.

Methods

From the REAL-CAD study comparing high-dose with low-dose pitavastatin therapy in Japanese patients with stable coronary artery disease, 11105 patients without reported non-adherence for the study drug were divided into 3 groups according to the on-treatment LDL-C level at 6-month (<70 mg/dL, 70–100 mg/dL, and ≥100 mg/dL; N=1016, N=3078, and N=1665 in the pitavastatin 1 mg/day stratum; N=2431, N=2524, and N=391 in the pitavastatin 4 mg/day stratum). Primary outcome measure was a composite of cardiovascular death, non-fatal myocardial infarction, non-fatal ischemic stroke, or unstable angina requiring emergent admission.

Results

In the pitavastatin 1 mg/day stratum, cumulative 4-year incidence of the primary outcome measure was not significantly different across the 3 groups (5.0%, 5.7%, and 5.2%, P=0.51), while in the 4 mg/day stratum, it was significantly higher in the LDL-C ≥100 mg/dL group than in other groups (4.5%, 3.4%, and 9.1%, P<0.001). The adjusted risks of the LDL-C <70 mg/dL group relative to the LDL-C 70–100 mg/dL group (reference) remained insignificant for the primary outcome measure in both 1 mg/day and 4 mg/day strata (HR 0.84, 95% CI 0.58–1.18, P=0.32, and HR 1.25, 95% CI 0.88–1.79, P=0.22). The adjusted risk of LDL-C ≥100 mg/dL group relative to the reference group was not significant for the primary outcome measure in the 1 mg/day stratum (HR 0.82, 95% CI 0.60–1.11, P=0.21), while it was highly significant in the 4 mg/day stratum (HR 3.32, 95% CI 2.08–5.17, P<0.001). In the on-treatment LDL-C ≥100 mg/dL group in the 4 mg/day stratum, LDL-C increased by 6.3 mg/dL from baseline to 6-month despite dose escalation of pitavastatin from 1 mg/day to 4 mg/day, suggesting the presence of unreported poor adherence in this small subgroup.

Adjusted Effects of On-treatment LDL-C

Conclusions

Very low on-treatment LDL-C level (<70 mg/dL) was not associated with lower cardiovascular event risk compared with moderately low on-treatment LDL-C level (70–100 mg/dL) in patients receiving the same doses of statins. Too much emphasis on the target LDL-C strategy might mislead the clinical practice.

Acknowledgement/Funding

The Comprehensive Support Project for Clinical Research of Lifestyle-Related Disease of the Public Health Research Foundation.

P5600Surgical reconstruction of type A aortic dissection in octogenarians

Introduction

Because the population is aging, the indication for surgical reconstruction in older patients will increase. Japan is especially facing the most aging society worldwide. However, surgical reconstruction of type A aortic dissection (AADA) in patients who are octogenarians is not often performed because of the decision of the patient or surgeon. We examined the outcome of surgical reconstruction of AADA in octogenarians.

Method

Over 4 years, 132 cases of surgical reconstruction of AADA were analyzed. Twenty-five consecutive octogenarians with AADA were retrospectively reviewed. In our institution, we recommend an emergent operation to the patient or family in all generations unless they reject it for some reason.

Results

Operative factors in octogenarians with AADA were not significantly different compared with those in patients aged younger than 79 years (n=107) (operation: 238±11 vs. 246±5 min, p=0.54; cardiopulmonary bypass: 147±7.4 vs. 154±3.5 min, p=0.42; aortic-clamp: 114±6.0 vs. 120±2.8 min, p=0.36; hypothermic-arrest: 43±2.7 vs. 42±1.3 min, p=0.81). The overall mortality rate was 24.0% (n=6). The mortality rate was no difference between younger patients and octogenarians (OR: 2.7, 95% CI: 0.86–8.21, p=0.08). Furthermore, MACE (Major Adverse Cardiac Event) and the postoperative stroke rate were not significantly different between the two groups (OR: 1.5, 95% CI: 0.52–3.93, p=0.42; OR: 0.77, 95% CI: 0.16–2.59, p=0.69, respectively).

Conclusion

In AADA, the outcome of emergent surgical reconstruction in octogenarians is acceptable. Even with the risk of aging, surgeons should consider aggressive surgical reconstruction in octogenarians.

A case of coronary-pulmonary artery fistula with coronary artery aneurysm detected for Kawasaki disease remote phase

Follow-up echocardiography showed two coronary-pulmonary artery fistulae and a coronary artery aneurysm in a 12-year-old boy who had been diagnosed with Kawasaki disease without persistent coronary artery lesion at the acute phase when he was 6-months-old. Left coronary arteriogram confirmed the fistulae and the 4.3 × 6.3 mm aneurysm. Results show that the fistula is associated with Kawasaki disease.

P4731Procedure-related acute thrombosis after surgical left atrial appendage occlusion for atrial fibrillation

Background/Introduction

Left atrial appendage (LAA) occlusion is an effective strategy for thromboembolism prevention in patients with atrial fibrillation (AF), and the novel methods of occlusion is various. The acute thrombosis after percutaneous LAA occlusion devices has been recently reported, but thrombus formation after surgical LAA occlusion is still unclear.

Purpose

This study aimed to analyse the incidence and prognosis of thrombus formation on closure stump line in patients with AF who underwent surgical LAA occlusion.

Methods

This study retrospectively analised the data from patients treated with two methods of surgical LAA closure, resection or clipping, from January 2014 to November 2018.

Results

A total of 187 consecutive patients with AF underwent surgical LAA closure (31 clipping and 156 stapler resection). 170 patients (91%) underwent cardiac CT for LAA imaging on postoperative day 2. The incidence of acute procedure-related thrombus formation in full cohort was 19% (35 cases). The incidence of acute thrombus in patients with clipping and resection was 19% and 16%, respectively (Fisher's exact test, p=0.8). All of 35 patients who had thrombus on LAA closure stump line underwent cardiac CT again 3 months after the primary CT. In all patients with secondary cardiac CT, thrombus on LAA closure stump line disappeared. No symptomatic thromboembolism occurred during the follow-up from operation to secondary CT scan.

Conclusion(s)

Thrombus formation on stump after surgical LAA closure may often occur on acute phase. The optimal LAA imaging and anti-coagulation therapy after surgical LAA occlusion will prevent patients with acute thrombus from thromboembolism.

P1831Prediction of cardiovascular events by atheromatous plaques detected by non-obstructive general angioscopy: two-year results of EAST-NOGA Registry

Background

Non-obstructive general angioscopy (NOGA) has revealed the intimal damages or atheromatous plaques as well as its spontaneous rupture of the aorta. Recent study revealed that plaque debris or different size of cholesterol crystals were detected in the blood above the spontaneous ruptured aortic plaque observed by NOGA and these plaque materials might cause the peripheral organ damages as the embolic source. These various morphological changes may cause the acute aortic events or atheroembolic events on the peripheral organs, such as brain, kidney, peripheral artery and so on.

Purpose

EAST-NOGA (Evaluation of AtheroSclerotic and rupture events by Non-Obstructive General Angioscopy) is a multi-center prospective observational study to assess the relationship between the findings of NOGA and future cardiovascular events.

Methods

Five hundred and seventy-seven patients with atherosclerotic cardiovascular disease who underwent NOGA study. The major cerebrocardiovascular events including cardiovascular death, non-fatal myocardial infarction, non-fatal cerebral infarction, and acute aortic syndrome were accumulated during the 2-year follow-up after NOGA study.

Results

The median number of aortic atheromatous plaques was 6 [IQR: 3–12]. A total of 514 patients were followed up (89.1%). The mean follow-up duration was 757±120 days. Major adverse cardiovascular events developed in 23 (4.5%) during 2 years follow-up. Patients with MACE and cerebral infarction, had significantly greater number of aortic atheromatous plaques (11 [5–19] vs. 6 [3–11], p<0.001, 12 [4–20] vs. 6 [3–12], p=0.014, respectively). In a univariate analysis, the number of aortic atheromatous plaques and ruptured plaque were significant predictors of MACE (HR: 1.09 95% confidence interval 1.05–1.14, p<0.001) and (HR: 1.12, 95% confidence interval 1.02–1.23, p=0.02). In a multivariate logistic analysis, the number of aortic atheromatous plaques is one of the independent predictors of MACE (HR 1.05, 95% confidence interval 1.00–1.10, p=0.032).

Conclusion

The number of atheromatous plaques identified by NOGA has a significant relation to the onset of cerebral infarction, which suggest the atheromatous plaque were vulnerable and ruptured spontaneously, then cause the aortogenic cerebral infarction. The NOGA study would be useful for predicting the futured atheroembolic events.

Acknowledgement/Funding

None

Juvenile sclerosing polycystic adenosis cytologically mimicking Warthin tumor

Sclerosing polycystic adenosis (SPA) is a rare salivary gland disease. Histologically it resembles a low-grade ductal carcinoma in situ or sclerosing adenosis of the breast, characterized by lobular proliferation of ducts with apocrine cellular features surrounded by fibrosclerotic stroma. Although SPA is typically benign, recurrence is not uncommon, and cases with a malignant component have been documented. Thus, complete excision is desirable but preoperative diagnosis is challenging. A 12-year-old boy presented with a painless mass in the right neck. We identified a well-demarcated mass in the right parotid region measuring approximately 2 cm using cervical echography and magnetic resonance (MR) imaging. Fine-needle aspiration (FNA) revealed two cell types. There were loosely cohesive clusters of polymorphic epithelioid cells with irregular nuclei and abundant vacuolated cytoplasm containing zymogen granules. Some of these cells were binuclear. The other cell types represented normal ductal cells. The original cytological diagnosis was Warthin tumor. Right parotidectomy was performed. Histologically, we observed proliferation of ducts with granular, vacuolated, zymogen granules, and apocrine-like features in the cytoplasm with hyalinizing sclerotic stroma and some binuclear cells. Four years after parotidectomy, there has been no recurrence or malignant transformation.Cytological diagnosis of SPA is challenging on FNA specimens since SPA is a very rare entity of the salivary gland that can mimic other salivary gland neoplasms. A mixture of apocrine-like cells and sebaceous-like cells, nuclear pleomorphism, and zymogen granules can help to diagnose this rare lesion during the initial cytological diagnosis.

Resection of Cerebellopontine Angle Meningioma via Retrosigmoid Approach Aiming for Hearing Improvement

We present a 71-year-old female case of left cerebellopontine angle (CPA) meningioma who presented with progressive hearing loss. The tumor was 35 mm in maximum diameter, obviously compressed the brain stem and cerebellum, and also displaced cranial nerves 7th and 8th anteriorly ( Fig. 1 ). Retrosigmoid approach was chosen to resect the tumor aiming for hearing improvement. We performed dissection of the tumor from cranial nerves 7th and 8th gently and resection of the tumor except for the part adhesive to these cranial nerves ( Fig. 2 ). Postoperative course was good without any new neurological deficit. Postoperative examination also showed improvement of high-frequency hearing of the left side, and auditory brainstem response demonstrated wave 2 to 5, which was not identify on preoperative examination. These procedures enabled safe and effective resection of the tumor and contributed to hearing improvement.

The link to the video can be found at: https://youtu.be/hkRSCxtV3bY .

[A case of lymphomatosis cerebri rapidly confirmed by brain biopsy]

Lymphomatosis cerebri (LC) is a variant of primary central nervous system lymphoma, which demonstrates diffuse white matter infiltrates without showing definite enhanced mass lesions on MR scans. We present a case of seventy-one year-old immunocompetent male who manifested with progressive truncal ataxia and drowsiness. The MRI exhibited diffuse white matter lesions from brainstem to cerebral hemispheres with minimum enhanced lesions at the first presentation. Because the diagnosis of LC was suspected, we performed a brain biopsy from the enhanced lesion near the right thalamus, which revealed diffuse large B cell lymphoma. After he underwent methylprednisolone pulse therapy and methotrexate chemotherapy, he obtained remission. Making a diagnosis of LC is often difficult because image findings resemble those of inflammatory or autoimmune diseases. LC is an important differential diagnosis to be considered in patients presenting with diffuse white matter disease. Performing a brain biopsy at the early phase is essential for the correct diagnosis and the favorable prognosis.

Recurrent Aphthous Stomatitis Caused by Cytomegalovirus, Herpes Simplex Virus, and Candida Species in a Kidney Transplant Recipient: A Case Report

Recipients of organ transplants are immunosuppressed and at high risk of oral infection. Oral diseases are often neglected compared with infections of other organs that typically confer higher morbidity. However, severe local symptoms hinder oral intake, decrease quality of life, and are sometimes lethal. Here we describe a case of a 57-year-old woman who developed recurrent aphthous stomatitis after kidney transplantation; the cause of the infection was complex and included cytomegalovirus, herpes simplex virus, and Candida species. Since misdiagnosis of oral diseases impairs patient quality of life and increases morbidity, clinicians should be aware of possible etiologies of oral infections in renal transplant recipients.

SMARCB1/INI1 Is Diagnostically Useful in Distinguishing α-Fetoprotein-producing Gastric Carcinoma from Hepatocellular Carcinoma

BACKGROUND/AIM

Switch/sucrose non-fermentable (SWI/SNF)-related, matrix-associated, actin-dependent regulator of chromatin subfamily B member 1 (SMARCB1), also named integrase interactor 1, is one of the core subunit proteins in the SWI/SNF ATP-dependent chromatin remodeling complex encoded at chromosomal position 22q11.2. Complete loss of SMARCB1 expression has been reported in various malignant tumors. Immunohistochemistry has demonstrated that SMARCB1 mutation/inactivation correlates well with loss of nuclear SMARCB1 expression. This study investigated SMARCB1 expression in hepatocellular carcinomas (HCCs) and α-fetoprotein (AFP)-producing gastric carcinomas by immunohistochemistry. For comparison, SMARCB1 immunostaining in intrahepatic cholangiocarcinoma (ICC) was also performed.

MATERIALS AND METHODS

Thirty classical HCCs, 30 ICCs and 10 AFP-producing gastric carcinomas were analyzed.

RESULTS

Only one case of HCC had focal labeling of SMARCB1 in the nuclei. Twelve cases of ICC were immunopositive for SMARCB1, with either focal or diffuse reactivity. All AFP-producing gastric carcinomas were immunopositive for SMARCB1 in the nuclei, and the reactivity was consistently diffuse.

CONCLUSION

SMARCB1 is a potential marker for distinguishing metastatic AFP-producing gastric carcinoma from HCC.

Effective multiple sideband generation using an electro-optic modulator for a multiple isotope magneto-optical trap

Herein, we report an effective method for the generation of radio-frequency (RF) sidebands in an electro-optic modulator for the simultaneous magneto-optical trapping of two isotopes. This is achieved by switching the RF signals alternately, which suppresses the generation of unwanted frequency signals and improves the laser power per sideband. The generated sidebands are successfully applied to a dual-rubidium-isotope magneto-optical trap (MOT), which results in an increased number of trapped atoms. This simple, flexible, and robust technique can be implemented in experiments that require a large number of atoms in multiple-isotope MOTs and for various applications.

Search for CP Violation in Neutrino and Antineutrino Oscillations by the T2K Experiment with 2.2×10^{21} Protons on Target

The T2K experiment measures muon neutrino disappearance and electron neutrino appearance in accelerator-produced neutrino and antineutrino beams. With an exposure of 14.7(7.6)×10^{20} protons on target in the neutrino (antineutrino) mode, 89 ν_{e} candidates and seven anti-ν_{e} candidates are observed, while 67.5 and 9.0 are expected for δ_{CP}=0 and normal mass ordering. The obtained 2σ confidence interval for the CP-violating phase, δ_{CP}, does not include the CP-conserving cases (δ_{CP}=0, π). The best-fit values of other parameters are sin^{2}θ_{23}=0.526_{-0.036}^{+0.032} and Δm_{32}^{2}=2.463_{-0.070}^{+0.071}×10^{-3}  eV^{2}/c^{4}.

Cytomegalovirus Hemorrhagic Cystitis in a Malignant Glioma Patient Treated with Temozolomide

Temozolomide, a key drug in the treatment of malignant glioma, can cause profound lymphopenia and various opportunistic infectious diseases. A 79-year-old woman with anaplastic oligodendroglioma developed a fever and gross hematuria after 8 weeks of standard radiotherapy with concomitant temozolomide treatment. A cytomegalovirus (CMV) antigen test for pp65 antigenemia was positive (137 cells per 75,800 leukocytes), and the findings from a urine cytology test were consistent with CMV-induced hemorrhagic cystitis. She was treated with ganciclovir, and her condition improved. CMV monitoring is needed when patients develop symptoms related to opportunistic infections during temozolomide treatment for malignant glioma.