Intravascular lymphomatosis diagnosed by transbronchial lung biopsy

Intravascular lymphomatosis is a rare lymphoma presenting a variety of symptoms due to proliferation of tumour cells within blood vessels in the brain, the skin and other organs. This disease is generally considered to be highly malignant, but to be relatively susceptible to combined chemotherapy, when diagnosed in the early stage. We describe a case of intravascular lymphomatosis, presenting with diffuse interstitial shadows on chest radiographic image, which could be diagnosed by transbronchial lung biopsy. The patient showed a good response to combined chemotherapy. We propose that transbronchial lung biopsy is a useful procedure for the diagnosis of intravascular lymphomatosis.

[Histopathological examinations of dural arteriovenous malformations of posterior fossa]

Two cases of dural arteriovenous malformation (DAVM) of the posterior fossa were presented and a histopathological examination was described. After embolization of the feeding arteries, DAVMs of the posterior fossa were removed with the adjacent sinus. Serial sections of the surgical specimens showed an abnormal mass with dilated, tortuous vessels of varying diameters in the sinus wall, and partially hyalinized connective tissue around the vessels. The elastic lamina of the sinus wall was interrupted and a mass of abnormal vessels developed into the subintimal layer of the sinus. Fistulas, about 200 microns in diameter, were formed between arterialized dural veins and dural arteries which had obvious internal elastic lamina. An opening of the fistula of the abnormal vessel, 25 microns in diameter, to the sinus lumen was also seen. No stage of organized thrombus could be seen in the sinus lumen. These findings strongly suggested that physiologically existing arteriovenous fistulas within the dura mater, which have been reported by Kerber et al, had developed due to many factors which increase intracranial pressure. They protruded into the sinus lumen in such a way that it could cause stenosis or obstruction of the sinus. In conclusion it can be said that an obstructive lesion of dural sinus is considered of itself to be DAVM in most cases and sinus thrombosis is the result of the DAVM.

Molecular cloning of a novel trypsin-like serine protease (neurosin) preferentially expressed in brain

A cDNA encoding a precursor for a novel serine protease (neurosin) was cloned from a cDNA library prepared from a human colon adenocarcinoma cell line, COLO 201. The sequence consisted of 155 bp 5' non-coding region and a 732 bp open reading frame which was followed by a 551 bp 3' non-coding region. The predicted protein consists of 244 amino acids which is possibly processed to an active enzyme of 223 amino acids that shows some similarity (< 30%) to other members of serine protease family. As found in other trypsin-like proteases, the enzyme contains the catalytic triad which is characterized as the essential amino acid residues for the activity. Northern blot analyses of the mRNA showed the strongest expression in brain followed by a lower but significant one in spleen. A construct of cDNA encoding chimeric protein that carries pro-sequence of trypsin II and putative mature neurosin starting from Leu22 was transfected to COS-1 cells. Successful production of the active neurosin was shown after treating the supernatant of the culture of the transfectants with enterokinase.

[Transarterial platinum coil embolization for direct carotid-cavernous fistula]

Two cases of direct carotid-cavernous fistula (CCF) were treated by transarterial platinum coil embolization (TACE) following unsuccessful transarterial balloon embolization (TABE). Case 1 was a 47-year-old man who complained of pulsatile left exophthalmos, chemosis and bruit. Left carotid angiograms showed a CCF with anterior, posterior and cortical venous drainage. Near total obliteration of the CCF was achieved by TABE, but it showed recurrence in the next morning. At this time, left carotid angiograms showed a CCF which drained only into the cortical veins via the enlarged sphenoparietal sinus. Because of high risk of intracranial hemorrhage, TACE was performed immediately. The result was successful. Case 2 was an 82-year-old woman who suffered from traumatic subarachnoid hemorrhage. First right carotid angiograms showed a small CCF which drained only into the inferior petrosal sinus. Right exophthalmos, swelling of the eyelids, severe eye pain and bruit appeared gradually. The second right CAG performed three months after the head trauma showed markedly dilated superior ophthalmic vein which was the new main draining root of the CCF. Because of progressive symptoms, TACE was performed immediately after the angiography, which proved successful. Direct CCFs must be treated aggressively because they don't cure by spontaneous obstruction of fistula. Although TABE is the first choice for direct CCF, complete occlusion of CCF in difficult in some cases. Those cases have; 1) small fistula of CCF for balloon insertion, 2) large fistula for occlusion by balloons, 3) not enough space for inserting a balloon after recurrence of CCF, and 4) sharp objects (bone fracture fragments, foreign objects) may puncture the balloon. If TABE couldn't provide successful treatments, TACE should be considered as an alternative treatment for direct CCF after angiography without delay because it is less complex compared with TABE.

[Usefulness of MRA in an infant with cerebral infarction due to streptococcal meningitis]

We described a 4-month-old boy with cerebral infarction due to streptococcal meningitis. He complained of cough and high fever for 2 days. On the next day he admitted to our hospital because of bad humor, drowsiness, and vomiting associated with high fever, respiratory failure and loss of consciousness. On admission, he had opisthotonic posturing, anisocoria and elevated deep tendon reflexes with left side dominance. The cerebrospinal fluid showed increased cells (564/mm3), protein (295 mg/dl), and decreased sugar (1 mg/dl). Streptococcus pneumoniae was detected in the cerebrospinal fluid. Despite intensive treatment by antibiotics, glycerol, and dexamethasone, general condition was worsened, MRI showed a high intense area along the territory of bilateral anterior cerebral arteries and left middle cerebral artery 3-D time-of-flight MRA revealed a decreased signal of these arteries, confirming cerebral infarction. Recanalization of the arteries were observed 17 days after the first MRA examination. Since complication of cerebral infarction influences the prognosis of meningitis, repetitive MRA is very beneficial in patients with bacterial meningitis in order to evaluate the vascular lesion.

Beneficial effects of administering intraportal prostaglandin E1 postoperatively to hepatectomy patients with massive intraoperative blood loss

Massive intraoperative blood loss is a major cause of complications following hepatectomy. To evaluate the efficacy of intraportal prostaglandin E1 (PGE1) for preventing liver deterioration in hepatectomy patients with an intraoperative blood loss of over 2000 ml, a retrospective analysis was conducted on 10 patients given intraportal PGE1 (portal group), 6 given intravenous PGE1 (venous group), and 10 given no treatment (control group). PGE1 was infused at 250 or 500 micrograms/day in the portal group and at 720 micrograms/day in the venous group, and continued for 3 days postoperatively. Alanine aminotransferase (ALT) and total bilirubin (T.Bil) were measured on postoperative days (PODs) 1, 3, 5, and 7. ALT was lower in the portal group than in the other two groups on each POD, and significantly lower than in the control group on POD3 (P < 0.05). T.Bil was significantly lower in the portal group than in the control group on PODs 5 and 7 (P < 0.05). T.Bil on POD 7 was under 1.5 mg/dl in 1 (10.0%), 6 (60.0%), and 2 (33.3%) of the control, portal, and venous group patients, respectively, with a significant difference between the control and portal groups (P < 0.05). These results confirmed that intraportal PGE1 was beneficial for improving hepatic function and preventing cholestasis in patients with a blood loss of over 2000 ml at risk of developing postoperative liver deterioration.

Regulation of L-DOPA production by genetically modified primary fibroblasts transfected with retrovirus vector system

Although intracerebral grafting has become established as a new strategy for the treatment of Parkinson's disease, there are many problems regarding such grafts. We focused on the grafting of primary skin fibroblasts. Rat primary skin fibroblasts were transfected with a retrovirus vector containing cDNA of human tyrosine hydroxylase (TH) type 1 (LTHSNL) or of cytomegalovirus promoter (CTHSNL) as a foreign promoter. In these genetically modified fibroblasts, L-DOPA production and release were analyzed in vitro by immunocytochemistry and high-performance liquid chromatography with electrochemical detection (HPLC-ECD). Being supplemented with the biopterin (BH4:(6R)-L-erythro-tetrahydrobiopterin) cofactors required for TH activity, these cells produced and released L-DOPA into the culture medium. When CTHSNL and BH4 were combined, L-DOPA production increased with time, regardless of the number of cell passages, or the duration of liquid nitrogen freezing. This suggests that the foreign gene (THcDNA) containing retrovirus vector integrates into the chromosomal DNA of the target cells (fibroblasts). Primary fibroblasts can be easily obtained and cultured. Thus, genetically modified primary skin fibroblasts transfected with a retrovirus vector system containing the TH cDNA may be promising grafts for transplantation and gene therapy in Parkinson's disease.

[Percutaneous endoscopic gastrostomy in patients with swallowing difficulties--home care and long-term result]

We studied the possibility of home care of patients who are unable to swallow. Postsurgical complications during the short term (within a week), medium term (within a month) and long term (more than a month) were recorded along with survival time. We also retrospectively studied the number of patients who were discharged after percutaneous endoscopic gastrostomy from November 1989 to March 1995. The percentage of patients with short-term postsurgical complications was 12.1%. Vomiting was the most frequent complication during the medium term and the long term. The weekly rate of complication development (total complications number/total survival time) was highest in the short term and decreased year by year. It was lower in those who were discharged from the hospital than in those who were not discharged. The average survival time was 460.2 days (544.7 days: home care group, 419.0 days: hospital group). The one-year survival rate was 58%, and the two-year survival rate was 36%. One third (32.8%) of patients were cared for at home after gastrostomy (average duration of care at home: 338.5 days) and the average duration of care at home as a percentage of survival time was 58.8%. We conclude that Percutaneous endoscopic gastrostomy can improve the quality of life of patients who are unable to swallow, and may allow them to be cared for at home.

Kaposi's sarcoma associated with lung cancer and immunosuppression

We report a 65-year-old Japanese woman with Kaposi's sarcoma (KS). The eruption first occurred on the legs while she was admitted for treatment of poorly differentiated lung cancer. Approximately eight months after the evolution, cutaneous tumors rapidly spread to the forearms, trunk, and pharynx. At that time, the patient had received systemic corticosteroid (10-40 mg/day of prednisolone) for about three months to reduce pulmonary inflammation. The laboratory data showed anemia, lymphopenia, hypogammaglobulinemia, and a decreased T cell count, although the serological test for HIV infection was negative. The patient was treated with radiation (X-ray for KS of pharynx and electron beam for KS of lower legs) and local intralesional injection of vinblastine. Although both therapies were very effective and well tolerated, she died of bacterial pneumonia and sepsis. Autopsy revealed KS tumors, unknown before death, in both lungs, the esophagus, and the stomach. The left lung cancer had disseminated and metastasized to the right lung, pleura, mediastinum, and abdominal cavity. It is suspected that chronic respiratory distress and systemic use of corticosteroids might have induced the rapid extension of KS.

Hyperplastic callus formation in both femurs in osteogenesis imperfecta

A 3-year-old boy with osteogenesis imperfecta had hyperplastic callus formation in the right femur, without preceding trauma or fracture. Radiologically, this bony mass in the femoral shaft mimicked osteosarcoma. Open biopsy showed that it was benign and suggested hyperplastic callus formation. Seven months after the biopsy, the hyperplastic callus had practically vanished. A similar process developed in the left femur 1 year later, also without fracture.

[A successfully operated case of tuberous sclerosis presenting with intractable epilepsy]

A 20-year-old male patient with tuberous sclerosis was admitted to our hospital complaining of intractable epilepsy. He had been suffering from frequent seizures despite anticonvulsant treatment since the age of 1 year. CT scan and magnetic resonance images showed multiple calcified lesions at the paraventricle and temporal lobe on both sides. Electroencephalogram showed left temporal lobe dominant spike waves. After deep electrodes were inserted into the left amygdala and hippocampus and subdural electrodes were placed on the left temporal cortex, clinical seizures were monitored by video and EEG. The primary focus was found in the amygdala. Left temporal lobectomy was carried out through the cranio-orbital zygomatic approach. Postoperatively, the patient has been seizure-free for one year. Despite multiple intracerebral lesions in tuberous sclerosis, resection of the primary epileptogenic focus is needed to solve the seizure problem if the focus is localized.

Eosinophils negatively regulate eosinophilopoiesis by decreasing IL-5 levels

The effect of mature eosinophils on eosinophilopoiesis was studied. Mature eosinophils decreased the interleukin-5 (IL-5) level after incubation with IL-5 and suppressed IL-5 release from non-adherent mononuclear cells. These findings suggest that eosinophils negatively regulate eosinophilopoiesis by decreasing the IL-5 level.

[A case of sarcomatoid carcinoma of the urinary bladder]

We reported a case of sarcomatoid carcinoma of the bladder in a 62-year-old man admitted to our hospital because of intermittent macroscopic hematuria. Under the diagnosis of invasive bladder tumor, the patient underwent radical cystectomy and construction of an ileal conduit. Microscopic examination showed a tumor composed of spindle cells that are arranged in a storiform pattern reminiscent of that seen in malignant fibrous histiocytoma without any component of obvious epithelial tumors. Immunohistochemical examination showed that the spindle cells were positive for cytokeratin and we diagnosed the tumor as sarcomatoid carcinoma. The patient has remained well without any evidence of recurrence for 30 months after radical cystectomy. The distinction between sarcomatoid carcinoma that lacks conventional epithelial component and MFH is very difficult and important.

Serum concentrations of IL-5, GM-CSF, and IL-3 and the production by lymphocytes in various eosinophilia

The concentrations of interleukin-5 (IL-5), granulocyte-macrophage colony-stimulating factor GM-CSF, and interleukin-3 (IL-3) in serum and in IL-2-stimulated lymphocyte culture medium (L-IL2-CM) prepared from patients with reactive eosinophilia were measured by enzyme-linked immunosorbent assay (ELISA). Serum IL-5 levels were increased in 16 out of 42 cases. GM-CSF and IL-3 were below the detectable levels in all sera examined. The concentrations of IL-5 and GM-CSF in L-IL2-CM were increased in 10 out of 29 patients. IL-3 was below the detectable levels in all L-IL2-CM.

Prognostic significance of an interface pattern of central fibrosis and tumor cells in peripheral adenocarcinoma of the lung

Fifty-nine surgically resected pulmonary adenocarcinomas were histologically classified into four types (A, B, C, and D) according to the pattern of invasion, ie, the extent of invasive tumor cell growth in the interface zone between alveoli replaced by cancer cells and the central region of fibrosis (so-called "scar"). In pattern A cancer cells proliferate along the alveolar walls without forming a frankly invasive lesion. In pattern B invasive lesions occupy less than 30% and in pattern C more than 30% of the fibrosing area. Pattern D refers to invasion of the bronchial lumen by cancer cells. The 59 tumors included 14 of pattern A, 12 of pattern B, 16 of pattern C, and 17 of pattern D. The 5-year survival rate for patients with pattern A tumors was 100%, and the rates for patients with pattern B, C, and D tumors were 64.2%, 30.0%, and 11.8%, respectively. Each difference between pairs of survival curves was statistically significant (P < .05). We found a correlation between the pattern of invasion and other prognostic factors. However, even in the cases evaluated as favorable by other prognostic factors (stage I, tumor less than 35 mm in diameter, negative for lymph node metastases, well-differentiated histology, negative for subpleural invasion, negative for vascular invasion) the survival curves became steeper going from pattern A to patterns B, C, and D. We conclude that the pattern of invasion is correlated with the prognosis of surgically treated patients. Our study may provide new histological criteria for the prognostic evaluation of pulmonary adenocarcinoma.

IL-5 mRNA expression in blood lymphocytes from patients with Kimura's disease and parasite infection

Blood lymphocytes from patients with eosinophilia are known to produce interleukin-5 (IL-5) with appropriate stimulation in vitro. To determine whether blood lymphocytes from these patients produce IL-5 in vivo, we tested the IL-5 mRNA expression in blood lymphocytes immediately after separation by reverse-transcriptase polymerase chain reaction (RT-PCR) method. We found that lymphocytes from eosinophilic patients expressed IL-5 mRNA, but lymphocytes from normal volunteers did not express the lymphokine. These findings suggest that in patients with eosinophilia, peripheral blood lymphocytes produce IL-5 in vivo.

[Sequential change of cerebral angiography in a case of cerebral angiitis following herpes zoster ophthalmicus]

Delayed neurological symptoms and signs following herpes zoster ophthalmicus (HZO) such as "Delayed contralateral hemiplegia with HZO" are supposed to be due to ipsilateral intracranial angiitis and ischemic disorder. We experienced a rare case with ipsilateral cerebral hemorrhage following HZO. Under the diagnosis of cerebral angiitis associated with HZO, we treated her conservatively and observed sequential change of angiography for four months. A 54-year-old female, who had been treated for systemic lupus erythematosus (SLE), developed HZO on left ophthalmic nerve area. Seven weeks after the onset of HZO, she complained of headache, mild right hemiparesis, and disturbance of consciousness. Computed tomography revealed subcortical hemorrhage at the left temporo-occipital lobe. Cerebral angiography showed vascular irregularities such as segmental narrowing and sausage-like dilation on proximal portion of the ipsilateral anterior, middle and posterior cerebral arteries. Same findings were seen on peripheral portions of the posterior cerebral artery on the same side. Moreover sequential angiograms showed appearance of an aneurysm in the left middle cerebral artery (M2 potion). Under the diagnosis of cerebral angiitis associated with HZO, she was treated with antiviral agents, antiplatelet drugs, steroid and stellate ganglion block. Those irregularities were found to diminish on the sequential angiograms, and the aneurysm disappeared four month later.

Establishing diagnosis of pulmonary malignant lymphoma by gene rearrangement analysis of lymphocytes in bronchoalveolar lavage fluid

We report the successful application of gene rearrangement analysis to the lymphocytes obtained by bronchoalveolar lavage (BAL) for the diagnosis of pulmonary malignant lymphoma. A 45-yr-old female patient who had been suffering from back pain was shown to have macroglobulinemia and pulmonary infiltrative shadow by chest radiography. Transbronchial lung biopsy revealed a small B-cell infiltrate with monotypic immunoglobulin expression (IgM/kappa light chain), and malignant lymphoma was highly suspected. BAL was performed to evaluate the cell profiles. The phenotyping of lavaged lymphocytes by flow cytometry revealed that the major component of the lymphocytes was CD3-positive T cells, and that CD21-positive B cells accounted for only 10% of all lymphocytes. This result was contradictory to the immunohistochemical population of lymphocytes in biopsied specimens. However, gene analysis of lavaged lymphocytes revealed positive immunoglobulin heavy chain rearrangement and negative immunoglobulin light chain and T-cell receptor rearrangement, suggesting that B cells making up a minor population of lavaged lymphocytes were proliferating monoclonally. Thus, in this case, gene analysis was an effective procedure for detecting the origin of tumor cells and distinguishing monoclonality from reactive accumulations. To our knowledge, this case represents the first reported application of gene rearrangement analysis to cells obtained by BAL. The sensitivity and usefulness of this analysis for the accurate evaluation of pulmonary lymphoproliferative lesions, when applied to BAL cells, should be emphasized.

Increase of hepatic mRNAS of profilin, actin and extracellular matrix proteins after carbon tetrachloride treatment and partial hepatectomy in rats

The synthesis of liver collagen increases during the fibrotic process after administration of carbon tetrachloride and during regeneration after partial hepatectomy in rats. In the present study, we investigated the behavior of profilin and actin mRNA under such conditions. Profilin and actin mRNA increased after acute and chronic treatments of carbon tetrachloride, which is associated with the increase of fibronectin, type-III and -IV collagen mRNA. Furthermore, a simultaneous expression of profilin, actin and extracellular matrix proteins was observed during the regeneration of rat liver, that is, all mRNAs of these proteins showed biphasic peaks around 6 h and 48 h after partial hepatectomy. These results suggest that possible coupling might occur between the changes of extracellular matrix and the reorganization of actin cytoskeleton in vivo.

Changes in portal hemodynamics and hepatic function after partial splenic embolization (PSE) and percutaneous transhepatic obliteration (PTO)

Since April 1985, we have performed a multidisciplinary therapy consisting of partial splenic embolization (PSE), percutaneous transhepatic obliteration (PTO) or transileocolic vein obliteration (TIO), and endoscopic injection sclerotherapy (EIS) for patients with severe gastroesophageal varices and those with a portacaval shunt associated with portal hypertension. In this study, PSE and percutaneous transhepatic portography (PTP) were performed at the same time in seven liver cirrhosis patients with hypersplenism, gastroesophageal varices, or hepatocellular carcinoma. The changes in portal blood flow/pressure and hemodynamics were examined by a thermodilution method. The effects of PSE on blood biochemical parameters such as the platelet count, ICG R15, redox tolerance index (RTI), and oral glucose tolerance test (75 g OGTT) were also evaluated. PSE induced a decrease in the blood flow of the splenic artery and in the splenic vein pressure without decreasing the portal blood flow. The platelet count in the peripheral blood and the RTI increased significantly. These results suggest the possibility that PSE may reduce the potential perioperative risk in hepatocellular carcinoma complicated with liver cirrhosis.

Neurons with high-frequency discharge in the central nervous system in chronic pain

Prior to implantation of the thalamic- or motor cortex-stimulating electrodes for relieving chronic pain, extracellular unitary activity was recorded and local microstimulation was done, by using microelectrodes, mainly in the ventral caudal nucleus of the thalamus. A significant number of high frequency discharge neurons (hyperactive neurons) were recorded and showed three types of discharge patterns with different interval histograms. In animal experiments, unilateral dorsal root sectioning from C5 to Th1 of male Wistar rats was made according to the method of Lombard et al[4]. One to three months after the operation, cellular activity was recorded from the contralateral thalamic nuclei (VP, zona incerta), lemniscus medialis and striatum. Hyperactive neurons were recorded from the thalamic nuclei and lemniscus medialis. The firing patterns and distribution of hyperactive neurons in these animals were very similar to those of humans. Hyperactive neurons were examined via electrical stimulation of and/or iontophoretical application of chemical substances. Hyperactive neurons were unaffected by electrical stimulation of the nucleus raphe dorsalis and locus ceruleus. However, sensorimotor cortical stimulation showed a reduction of firing in the hyperactive neurons. Iontophoretic application of glutamate showed increase in firing and GABA showed remarkable firing suppression. These results suggested that hyperactive neurons of the thalamic nuclei receive a facilitatory effect from the sensorimotor cortex with little influence from adrenergic or serotonergic systems, and these neurons have a relationship to the glutamatergic and GABAergic fibers or receptors.