Analysis of Coronary Arterial Aneurysm Regression in Patients With Kawasaki Disease by Aneurysm Severity: Factors Associated With Regression

Background Coronary arterial aneurysms (CAAs) associated with Kawasaki disease (KD) significantly affect prognosis. However, the clinical course of CAAs and factors associated with CAA regression have not been well analyzed. Methods and Results The cohort of the Z-Score 2nd Project Stage study, a multicenter, retrospective, cohort study involving 44 institutions in Japan including 1006 patients with KD, was examined. CAAs were classified by the z score of their internal diameter in the acute phase: small (z<5), medium (5≤z<10), and large (z≥10). The lower limit of small CAA was based on the Japanese Ministry of Health, Labour and Welfare criteria. In the right coronary artery, the CAA regression rates 10 years after diagnosis were 95.5% for small, 83.2% for medium, and 36.3% for large. In the proximal left anterior descending artery, the regression rates 10 years after diagnosis were 95.3% for small, 80.1% for medium, and 28.8% for large. Cox regression analysis showed that diagnosis under the age of 1 year and onset of KD in 2010 to 2012 for the right coronary artery and the left anterior descending artery, and female for the right coronary artery were significantly associated with a high regression rate, whereas large CAAs for the right coronary artery and the left anterior descending artery were significantly associated with a low regression rate. Conclusions The current study, the largest Japanese study of its kind, found that small aneurysm, recent onset, and diagnosis under the age of 1 year predict regression, and that even giant aneurysms could regress. These data may contribute to long-term management of coronary aneurysms. Registration URL: https://www.umin.ac.jp/ctr/; Unique identifier: UMIN000010606.

Distinctive serum lipidomic profile of IVIG-resistant Kawasaki disease children before and after treatment

Kawasaki Disease (KD) is an acute inflammatory disorder associated with systemic vasculitis. Intravenous immunoglobulin (IVIG) is an effective therapy for KD, yet, about 20% of cases show IVIG resistance with persistent inflammation. The lipid profile in IVIG-resistant KD patients and the relationship between lipid characteristics and IVIG resistance remain unknown. In this study, serum samples from twenty KD patients with different IVIG responses (sensitive, intermediate, or resistant) were collected both before and after treatment, and lipidomic analysis was performed using high-performance liquid chromatography-mass spectrometry. As a result, before treatment, six lipid species were found as the most variant features, in which all the top decreased lipids in the IVIG-resistant group were lysophosphatidylcholine (LPC) and lysophosphatidylethanolamine (LPE), suggesting the potential to be IVIG-resistant markers in pretreatment diagnosis. During treatment, lipidomic changes showed a weaker response in the IVIG-resistant group. After treatment, LPC and LPE species exhibited lower in the IVIG-resistant group and negative correlation with the inflammatory markers, indicating that the unique metabolism may occur among IVIG-responsiveness. These results might contribute to diagnosing IVIG-resistant patients more accurately for alternative therapy and to a better understanding of how lipid metabolism is associated with IVIG sensitiveness/resistance in KD.

Successful recovery from severe hypertension in a patient with Leigh syndrome

Hypertension is a rare complication of Leigh Syndrome (LS), but prognosis of patients with hypertension is poor and its presence is indicative of the terminal stage of the disease. Herein, we report a four-year-old girl case diagnosed with LS at 15 months of age who subsequently developed severe hypertension and respiratory failure. Physical examination and laboratory findings did not indicate a secondary cause of hypertension. Her respiratory failure was treated with non-invasive ventilation and hypertension controlled with enalapril, furosemide and spironolactone. To our knowledge, this is the first case of a patient with LS recovering from severe hypertension.

Association of Severity of Coronary Artery Aneurysms in Patients With Kawasaki Disease and Risk of Later Coronary Events

IMPORTANCE

Few studies with sufficient statistical power have shown the association of the z score of the coronary arterial internal diameter with coronary events (CE) in patients with Kawasaki disease (KD) with coronary artery aneurysms (CAA).

OBJECTIVE

To clarify the association of the z score with time-dependent CE occurrence in patients with KD with CAA.

DESIGN, SETTING, AND PARTICIPANTS

This multicenter, collaborative retrospective cohort study of 44 participating institutions included 1006 patients with KD younger than 19 years who received a coronary angiography between 1992 and 2011.

MAIN OUTCOMES AND MEASURES

The time-dependent occurrence of CE, including thrombosis, stenosis, obstruction, acute ischemic events, and coronary interventions, was analyzed for small (z score, <5), medium (z score, ≥5 to <10; actual internal diameter, <8 mm), and large (z score, ≥10 or ≥8 mm) CAA by the Kaplan-Meier method. The Cox proportional hazard regression model was used to identify risk factors for CE after adjusting for age, sex, size, morphology, number of CAA, resistance to initial intravenous immunoglobulin (IVIG) therapy, and antithrombotic medications.

RESULTS

Of 1006 patients, 714 (71%) were male, 341 (34%) received a diagnosis before age 1 year, 501 (50%) received a diagnosis between age 1 and 5 years, and 157 (16%) received a diagnosis at age 5 years or older. The 10-year event-free survival rate for CE was 100%, 94%, and 52% in men (P < .001) and 100%, 100%, and 75% in women (P < .001) for small, medium, and large CAA, respectively. The CE-free rate was 100%, 96%, and 79% in patients who were not resistant to IVIG therapy (P < .001) and 100%, 96%, and 51% in patients who were resistant to IVIG therapy (P < .001), respectively. Cox regression analysis revealed that large CAA (hazard ratio, 8.9; 95% CI, 5.1-15.4), male sex (hazard ratio, 2.8; 95% CI, 1.7-4.8), and resistance to IVIG therapy (hazard ratio, 2.2; 95% CI, 1.4-3.6) were significantly associated with CE.

CONCLUSIONS AND RELEVANCE

Classification using the internal diameter z score is useful for assessing the severity of CAA in relation to the time-dependent occurrence of CE and associated factors in patients with KD. Careful management of CE is necessary for all patients with KD with CAA, especially men and IVIG-resistant patients with a large CAA.

Life-threatening QT prolongation in a boy with attention-deficit/hyperactivity disorder on atomoxetine

As a noncentral nerve-stimulating agent blocking reuptake of noradrenalin, atomoxetine is used for treatment of attention-deficit/hyperactivity disorder (ADHD). Because it has less potential for addiction and abuse and improves core symptoms of ADHD, it is commonly prescribed in many children and adolescents internationally. Its common side effects include headache, abdominal pain, decreased appetite, and weight loss. In addition, cardiac effects such as tachycardia and hypertension have also been reported. In this case report, an 11-year-old Japanese boy with a past medical history of ADHD on atomoxetine for more than 2 years presented with a loss of consciousness. Initial electrocardiogram (ECG) showed significant QT prolongation, and 9 h later, it worsened, along with bradycardia, inversed T waves, and multiple premature ventricle contractions (PVCs). Transthoracic echocardiography showed akinesis with dilation and systolic ballooning of the left ventricle's (LV) apical segment (Takotsubo cardiomyopathy). At that point, bisoprolol and transcutaneous pacing were started. After 5 days, transcutaneous pacing was discontinued due to improvement in his cardiac rhythm. He continued to remain asymptomatic for the next year, while his QT interval returned to normal. Conclusion: This case report suggests a serious side effect of atomoxetine, and to avoid life-threatening cardiovascular events for children and adolescents with ADHD on atomoxetine, prior screening for cardiovascular conditions by ECG with close monitoring is necessary.

Prolonged incubation period in neonatal Pasteurella multocida meningitis and bacteremia

Pasteurella multocida, often found as part of the human oral flora and in finger/toenails, also exists in many animals, especially cats, dogs, and pigs. Although rare, pasteurella infection in neonates can cause serious systemic disease, such as meningitis. In this article, a 23-day-old girl presented with decreased appetite and irritability for >2 days. Eighteen days previously her pet cat had jumped onto the left side of her head while she was sleeping. On laboratory data C-reactive protein was high, and on cerebrospinal fluid (CSF) analysis leukocyte count was extremely high, with low glucose and high protein. P. multocida grew out of the blood and CSF cultures, and she was successfully treated with antibiotics for 3 weeks. Although pasteurellosis rarely occurs, it can sometimes lead to life-threatening situations, so parents should exercise caution when having pets around their children.

Streptococcus pulmonary empyema after varicella infection in a serologically immunocompetent boy

Varicella zoster virus (VZV) is the etiologic agent of varicella, and it remains common among children in Japan due to low vaccination rates. It can cause a variety of serious and life-threatening complications. Generally, the most frequent complication of varicella in healthy children is bacterial superinfection, but empyema after VZV infection is a rare condition. This case report describes a previously healthy 21-month-old boy who attended nursery school with a recent varicella and group A β-hemolytic streptococcus (GABHS) pharyngitis outbreak and who presented with a 7 day history of vesicular rash along with progressive fever. Due to continued mild cough and prolonged fever, however, chest radiography was done, which showed a right pleural effusion. Further computed tomography showed a right pulmonary empyema, and purulent material was drained and eventually grew GABHS. This report hereby describes the development of pleural empyema caused by GABHS after VZV infection in a serologically immunocompetent patient.

USPIO-enhanced MRI of highly invasive and highly metastasizing transplanted human squamous cell carcinoma: an experimental study

OBJECTIVE

The aim of this study was to investigate the signal intensity characteristics of highly invasive and highly metastasizing transplanted human squamous cell carcinoma using ultra-small super-paramagnetic iron oxide (USPIO)-enhanced MRI and to correlate them with USPIO distribution to tumour components revealed by histological examination.

METHODS

13 nude mice with transplanted human squamous cell carcinoma in the oral cavity were imaged before and 24 hours after intravenous administration of USPIO. The difference in signal intensity between pre-contrast and post-contrast MR images was visually evaluated. For quantitative analysis, signal intensity within a region of interest was measured. Histological findings were correlated with MR findings. The approximate USPIO concentration was evaluated using USPIO phantoms.

RESULTS

Seven tumours had an area showing signal intensity increase on post-contrast T₁ weighted images. Histopathologically, six of those tumours contained a small amount of iron particles in the stroma. The USPIO concentration was presumed low. Two tumours had an area showing signal intensity decrease on post-contrast T₁ and T₂ weighted images. The areas had a large amount of iron particles in the stroma and the USPIO concentration was presumed high. There was a minimal amount of iron particles in tumour parenchymal cells.

CONCLUSIONS

The amount of USPIO accumulation into tumour stroma was considered to affect MR signal intensity. A small amount increases T₁ weighted signal intensity, whereas a large amount decreases T₁ and T₂ weighted intensity. The USPIO accumulation into the tumour parenchyma was not thought to affect MR signal intensity.

Amelogenin positive cells scattered in the interstitial component of odontogenic fibromas

BACKGROUND

Odontogenic tumours are often biphasic, consisting of epithelial and interstitial components, with an origin that is not well understood. Odontogenic fibromas are rich in mesenchymal component, but also have many epithelial nests.

AIMS

To investigate the origin of this tumour by immunohistochemistry.

METHODS

The expression of several odontogenic and epithelial markers, including amelogenin, was investigated by immunofluorescent studies.

RESULTS

Immunohistochemical analysis showed that epithelial nests exhibited E-cadherin expression, but not amelogenin. Amelogenin positive cells were scattered in the fibrous tissue, which did not exhibit epithelial marker expression except for epithelial membrane antigen. In one case that had received a test biopsy before whole resection of tumour, amelogenin positive cells were distributed in the regenerating mucosal epithelium or subepithelial tissue.

CONCLUSIONS

Results indicate that amelogenin positive cells of odontogenic fibromas have an epithelial origin and may have the potential for epithelial mesenchymal transition, which has not to date been investigated in benign tumours.

A potential pitfall of MR imaging for assessing mandibular invasion of squamous cell carcinoma in the oral cavity

BACKGROUND AND PURPOSE

Whether MR imaging is superior to CT in evaluating the presence and extent of mandibular invasion by squamous cell carcinoma remains controversial. The purpose of this study was to directly compare the diagnostic accuracy of MR imaging and that of CT.

METHODS

MR and CT images in 51 patients with squamous cell carcinoma of the oral cavity were evaluated for the presence and extent of mandibular invasion. The results were correlated with histopathologic findings.

RESULTS

Twenty-five of 51 patients had histopathologic evidence of mandibular cortical invasion. The tumor involved both the cortex and the bone marrow in all 25 patients and involved the inferior alveolar canal in 5 patients. The sensitivity and specificity for mandibular cortical invasion were 96% and 54% for MR imaging and 100% and 88% for CT, respectively. Those for inferior alveolar canal involvement were 100% and 70% for MR imaging and 100% and 96% for CT, respectively. In both evaluations, the specificity of MR imaging was significantly lower than that of CT (McNemar test, P = .004 in the former and P = .002 in the latter). Chemical shift artifact by bone marrow fat was postulated to be the source of most false-positive cases on MR imaging findings for mandibular cortical invasion. Those for inferior alveolar canal involvement were due to MR imaging visualization of the tumor and surrounding inflammation with similar signal intensity.

CONCLUSION

In assessing the presence and extent of mandibular invasion by squamous cell carcinoma, the specificity of MR imaging was significantly lower than that of CT.

High-resolution magnetic resonance imaging of squamous cell carcinoma of the tongue: an in vitro study

OBJECTIVES

To determine in vitro the potential of high-resolution MRI for evaluating the depth of tumor invasion of the tongue.

METHODS

Twenty-one resected specimens of squamous cell carcinoma of the tongue were examined on a 1.5T MRI system with a 4 cm surface coil using four different sequences; T1W SE, T2W SE, 3D-FISP and 3D-CISS. The thickness of normal epithelium, tumor depth and width were measured on both MR images and histopathological sections.

RESULTS

The mucosal epithelium, lamina propria and muscles of the tongue were clearly identifiable on MRI. All 21 carcinomas, including three early invasive carcinomas, were clearly demonstrated. A high correlation was found between the values measured by MRI and histopathology for thickness of mucosal epithelium and both depth and width of tumors. There was a good agreement between the T2W SE and the other imaging sequences for measurements of both depth and width of tumors.

CONCLUSION

High-resolution MR imaging appears reliable for the in vitro evaluation of depth of tumor invasion in carcinoma of the tongue.

Crossed linguo-buccal reflex in post-stroke patients

A pathological crossed orofacial reflex, called crossed linguo-buccal reflex in the present study, was observed in approximately 1/3 of post-stroke patients with central facial palsy. Stroking with pressure two or three times with a split wooden tongue-blade to the tongue or palate contralateral to the central facial palsy elicited a reflex movement consisting of retraction of the angle of mouth and medio-posterior withdrawal of the buccal mucosa on the paretic side. Seventy-seven patients with central hemifacial palsy caused by a unilateral cerebral lesion were examined clinically, electromyographically and by computed tomography (CT) and magnetic resonance imaging (MRI). In addition, three men with bilateral cerebral lesions and bilateral crossed linguo-buccal reflexes were electromyographically examined. Twenty-two patients with unilateral cerebral lesions had this reflex. It was found that this reflex was most frequently observed in patients with a capsulo-caudate lesion involving the head of the caudate nucleus, the anterior limb and genu of the internal capsule. The electromyogram of the reflex showed increased activity in the orbicularis oris, depressor anguli oris, risorius, zygomaticus major and buccinator muscles on the paretic side with a long latency (254-856 ms), and a prolonged after-discharge after the stimulation. Reciprocal inhibition was observed in patients with bilateral positive reflexes. These findings suggest that liberation of the polysynaptic brainstem reflex in the medulla oblongata and pons from the indirect corticobulbar inhibition may underlie the occurrence of the crossed linguo-buccal reflex in post-stroke patients.

Extremely thickened media of small pulmonary arteries in fatal pulmonary hypertension with congenital heart disease--a morphometric and clinicopathological study

There are patients with congenital heart disease and fatal pulmonary hypertension in whom the medial hypertrophy of the small pulmonary arteries is quite beyond the extent of ordinary cases of hypertension, a condition described as pulmonary hypertension with extremely thickened media of small pulmonary arteries (PH/ETM). Lungs from 6 infants, all younger than 2 years of age, who had congenital heart disease and fatal pulmonary hypertension, were analyzed by accurately measuring the media using Suwa's method. In PH/ETM, the media of the small pulmonary arteries was shown to be not only unusually thick, but extending toward the periphery, whereas the intimal changes were unexpectedly mild. In the PH/ETM group, the % wall thickness at a diameter of 50 microm (%Tw(50)), determined from regression analysis, was 23.2+/-1.3%, which was significantly higher than in either the control (10.3+/-1.2%) or ventricular septal defect group (18.9+/-1.6%). In persistent pulmonary hypertension of the newborn (PPHN), it was 22.3+/-1.8%, not significantly different from PH/ETM. The striking medial hypertrophy in PH/ETM and PPHN was apparently confined to small pulmonary arteries and in both conditions is likely to be the result of maldevelopment of these arteries. Surgical intervention may trigger a critical elevation of the pulmonary arterial resistance.

[Progressive paralysis of divergence in an adult with midbrain angioma]

A 37-year-old woman was admitted to the hospital with the complaint of progressive horizontal diplopia of six years' duration when viewing distant objects. On admission she had a slight left convergent strabismus. Homonymous diplopia was present beyond 50 cm and increased on distance fixation. Both eyes were fully mobile in the horizontal plane with a mild decrease in the velocity of horizontal eye movement to the left, and slight impairment of upward eye movement. The left eye did not fully adduct during convergence. The right pupil was slightly larger than the left. Prism cover test showed 6 delta esophoria at 30 cm and 14 delta esophoria at 5 m. The Hess chart showed a convergent deviation. MRI revealed a small right-side paramedian lesion of the midbrain tegmentum lying ventral to the aqueduct of Sylvius, at the level between the superior colliculi and the intercollicular area. A venous angioma with arteriovenous shunts in the right midbrain was diagnosed by angiography. We suggest that lesions that damage the divergence neurons in the tegmentum of the midbrain and also interrupt the supranuclear fibers having an inhibitory effect on the convergence neurons may produce homonymous diplopia on distant fixation combined with the esotropia.

Progressive pulmonary vascular disease after pulmonary artery banding and total correction in a case of ventricular septal defect and pulmonary hypertension

A 7-month-old infant with ventricular septal defect and pulmonary hypertension underwent pulmonary artery banding, which resulted in a decrease in the pulmonary arterial peak pressure from 102 to 54 mmHg. Lung biopsy findings showed at most an early grade 3 Heath-Edwards classification, and an index of pulmonary vascular disease of 1.4, both of which indicated operability for total correction. Small pulmonary arteries less than 100 microns in diameter, however, showed marked hydropic changes in the medial smooth muscle cells. Total correction was performed at the age of 2 years, but the pulmonary arterial pressure failed to decrease. A lung biopsy taken just after the closure of the ventricular septal defect contraindicated operability due to progressive pulmonary vascular disease at a grade 6 Heath-Edwards classification and an index of pulmonary vascular disease of 2.4. The patient died at 8 months after the operation, and an autopsy revealed still more advanced pulmonary vascular disease at a grade 6 Heath-Edwards classification and an index of pulmonary vascular disease of 2.8. The pathogenesis of arterial changes is discussed.

[Botulinum toxin therapy for cricopharyngeal spasm]

A 36-year-old woman presented an inability to ingestion and mild hemiparesis with superficial and deep sensory disturbances on the left side for two months after a stroke. Dysphagia was originated from bilateral cricopharyngeal spasm, which was disclosed by videofluorography, manometry at the pharyngo-esophageal segment, and needle electromyography. Although no focal lesion of the brain was detected even with MRI, neurological and electrophysiological findings suggested that the lesion was localized to the lower pontine and mudullary tegmentum on the right side. Two months after the onset, botulinum toxin (10 units) was administered into the bilateral cricopharyngeal muscles, which resulted in restoration of the normal swallowing function in 5 days, and the normal function is lasting 5 years. Botulinum toxin therapy is non-invasive and effective for cricopharyngeal spasm. This non-invasive method will be the first choice for cricopharyngeal spasm replacing surgical intervention.

[Disturbance of deep sensation in medial medullary syndrome. Topographical localization of medial lemniscus in the medulla oblongata]

Medial medullary infarction is characterized by ipsilateral hypoglossal nerve palsy with contralateral hemiparesis and disturbance of deep and discriminative sensory perception. We examined the extent and distribution of disturbances in deep sensation and compared the findings with the lesion location in the medial lemniscus detected by MRI in 3 patients with medial medullary infarction. We classified the lesion location into 2 groups; type I and type II. Type I was ventral to the middle medial lesion of the medial lemniscus, and type II was ventral to the dorsal medial lesion. In our series, type I (Case 1) impairment of the three kinds of deep sensations was more severe in the lower extremities than in the up-per extremities. In type II (Cases 2, 3) the severity or impairment in the upper extremities was moderate or severe and nearly equal to that in the lower extremities. There was no difference in the severity of impairment for the four kinds of discriminative sensations. In the literature, type I (8 patients) impairment of position sense in deep sensation was found in 1 of 7 patients in the upper extremities and 5 of 7 patients in the lower extremities. Impairment of vibration sense was found in 1 of 7 patients in the upper extremities and in all patients in the lower extremities. In type II (14 patients) severe impairment of position and vibration sense in deep sensation was found in 3 patients in the upper extremities equal to that in the lower extremities. There was no tendency in the severity of impairment of four kinds of discriminative sensations. Including our 3 cases and 22 in the literature, impairment of deep sensation was more severe in the lower extremities than in the upper extremities in type I (9 patients) and the extent was none (7), mild or moderate (2) in the upper extremities, mild (2), moderate (1), severe (2), obscure (4) in the lower extremities, while in type II (16 patients) the severity in the upper extremities was nearly equal to that in the lower extremities and the extent was none (1), mild or moderate (1), severe (5), obscure (9) in the upper extremities, none (2), mild or moderate (1), severe (6), obscure (7) in the lower extremities. It is concluded that hemiparesis appeared with lesions located in the pyramidal tract of the medulla, hemiparesis and disturbance of deep sensation in the upper and lower extremities, predominantly in the lower extremities with the lesion of the pyramidal tract to the middle of medial lemniscus in the medulla, hemiparesis and disturbance of the upper and lower extremities deep sensation with lesions of the pyramidal tract to the whole of the medial lemniscus in the medulla. Evaluating deep sensation of the upper and lower extremities is useful for speculation of the lesion location in the medial lemniscus in medial medullary infarction.

[Axial (neck and trunk) rigidity in Parkinson's disease, striatonigral degeneration and progressive supranuclear palsy]

Our previous study showed that the alternating knee tilt test in supine position is a useful method to assess the trunk rigidity. We investigated the progression of axial (neck and trunk) rigidity in Parkinson's disease (PD), striatonigral degeneration (SND), and progressive supranuclear palsy (PSP) by using this method. We assessed rigidity on a scale of 0 (absent) to 3 (severe) on five parts of the body: neck, trunk, wrist, elbow and knee in 57 patients with PD, 13 patients with SND and 18 patients with PSP. In PD patients, the degree of neck and trunk rigidity correlated well with the duration of disease and the staging scale. There was neck rigidity in 27% of PD patients with unilateral involvement of the limbs, but the trunk tonus was normal in them. There was rigidity in the neck and trunk of all PD patients with bilateral involvement of the limbs. When the limb rigidity was predominant on one side, the trunk rigidity was predominant on the opposite side. In SND patients, the degree of neck and trunk rigidity roughly correlated with the duration of disease and the staging scale. In SND patients with unilateral involvement of the limbs, tonus of the neck and trunk was normal. In SND patients with bilateral involvement of limbs, there was rigidity in both the neck and the trunk. In PSP patients, the degree of neck rigidity correlated well with the duration of disease and the staging scale, but the degree of rigidity in the trunk and limb remained relatively mild even at the advanced stage. Accordingly, in PSP patients there was a dissociation of the degree of neck rigidity from that of trunk and limb rigidity. In conclusion, the assessment of axial (neck and trunk) rigidity may be useful for the clinical diagnosis of parkinsonism and the staging scale scoring.

[Periodic decerebrate spasm with ocular dipping, Cheyne-Stokes respiration and hypersympathetic activity]

Decerebrate spasm is a generalized muscular spasm produced by some stimuli on decerebrate posture. Such spasm are called "tonic fit" or "decerebrate extensor spasm". We reported a 50-year-old man with periodic decerebrate spasm after cerebral hemorrhage. On admission, the patient was comatose. The pupils were round but anisocoric and did not react to light. Corneal reflexes were absent. The face, arms, and legs did not move voluntarily. Two weeks after admission, he was found in decerebrate rigidity. Periodic decerebrate spasms were also observed and were accompanied by ocular dipping. Cheyne-Stokes respiration, and hypersympathetic activity (transiently dilated pupils, hypertension, tachycardia). These symptoms persisted for two months and were induced by painful or sonic stimuli and suppressed by sleep, sedative or antiedematous drugs. The cycle was 0.6 approximately 0.7 per minute in accord with that of Cheyne-Stokes respiration. Magnetic resonance imaging revealed an area of low signal intensity in the midbrain to the bottom of the pons caused by the tentorial herniation on T1-weighted images. From the the clinical features and results of MRI studies, we considered that dysfunction of the midbrain to the pons in addition to diffuse cerebral dysfunction played some role in the manifestation of periodic decerebrate spasm with ocular dipping.

[Frontal type adrenoleukodystrophy: the progress of the white matter lesion--a neuroradiological and pathological study]

We studied the correlation between neuroradiological findings and pathological observations of white matter lesions in a patient with frontal type adrenoleukodystrophy. A 41-year-old man developed schizophrenic symptoms and generalized convulsions at the age of 40. Examination revealed baldness, loss of the axillary hair, stereotypical behavior, mutism, dysphagia echographia, right hemiparesis, and brisk reflexes in all four limbs with bilateral extensor plantar responses. Blood examination revealed a high concentration of very-long-chain fatty acids in plasma; the patient was diagnosed as having adrenoleukodystrophy. His condition continued to worsen, and gradually he became akinetic. He died of pneumonia at the age of 43. T1- and T2-weighted MR images distinguished three abnormal zones in the cerebral white matter in this case. In the first zone (Z1), the signal intensity was moderately high on T2-weighted images and slightly low on T1-weighted images; this zone was not enhanced with Gd-DTPA. In the second zone (Z2), the signal intensity was slightly high on T2-weighted images, while moderately low on T1-weighted images; Z2 was enhanced with Gd-DTPA. In the third zone (Z3), the signal intensity was markedly high on T2-weighted images and low on T1-weighted images; Z3 was not enhanced with Gd-DTPA. Z3 was located in the frontal pole; Z2 and Z1 were consecutively located in rostro-caudal fashion in the brain. The subsequent pathological study of the brain of this patient revealed the following findings: Z1 showed destruction of myelin with axonal sparing, Z2 showed numerous lipid-laden macrophages, demyelinated axons, and a vigorous perivascular mononuclear cell response, Z3 consisted of a dense mesh of glial fibrils and scattered astrocytes without any evidence of an active process. In this study, the correlation between MR images and pathological findings in adrenoleukodystrophy was clearly established. Single photon emission tomography with 99mTc-hexamethylpropyleneamine oxime, and positron emission tomography with 15O2 continuous inhalation technique showed a reduction in the regional cerebral blood flow (rCBF) and in the regional cerebral metabolic rate of oxygen (rCMRO2) in the cerebral cortex near the Z1 and Z3. A normal or slight increase of rCBF and a reduction of r CMRO2 was found in the cerebral cortex near the Z2. Coronal MR images showed that Z3 was located in the deep white matter, while Z2 and Z1 were consecutively located in an inner-outward fashion, suggesting that the demyelination process started in the cingulum and spread in an inner-outward fashion and progressed in rostro-caudal manner.

[A study on truncal rigidity in parkinsonism--evaluation of diagnostic test and electrophysiological study]

Truncal rigidity is regarded as a cause of axial motor disturbances such as difficulty in turning around and in rising from a recumbent position in parkinsonism. However, methodology for clinical evaluation of truncal rigidity has not yet been established. This study aims at developing a suitable bed-side technique to evaluate truncal rigidity in parkinsonism. Forty normal adults and fifty-one patients with Parkinson's disease or juvenile parkinsonism were examined. We tried to evaluate truncal tonus by twisting the subjects' body axis in a supine position. The subjects' axis was passively rotated by the examiner supporting and twisting the subjects' (1) shoulder, (2) axillas, (3) hips, and (4) knees. In comparing these four procedures, the maximal rotation of the axis was obtained easily with twists supporting the knees, that is alternating tilts of the bending knees rightward and leftward in a supine position. By this method of alternating knee tilts, the examiner felt merely a little resistance in twisting the normal subjects. On the other hand, in patients with parkinsonism, a considerable degree of resistance against twists was elicited, and the patients' side-was passively elevated from a bed in accordance with knee tilts. Electrical activities of the truncal muscles (M. erector spinae, M. obliquus abdominis externus and internus) during the alternating knee tilts were studied in ten normal adults and seventeen parkinsonian patients. Continuous electrical activities were present in the axial muscles, particularly at the thoracic level, which were passively stretched by this procedure in parkinsonism but never present in normals.(ABSTRACT TRUNCATED AT 250 WORDS)

[Shy-Drager syndrome and the syndrome of inappropriate secretion of antidiuretic hormone]

We report a 52-year-old male patient with Shy-Drager syndrome (SDS) complicated by an occurrence of the syndrome of inappropriate secretion of antidiuretic hormone (SIADH). The patient first developed impotence at the age of 48, accompanied by urinary incontinence, and episodes of dizziness while standing. The following year, the patient had developed a staggering gait and speech became monotonous. At age 52, the patient was admitted to the hospital after experiencing frequent episodes of syncope associated with complete loss of consciousness. Upon examination, blood pressure was 100/70 in a recumbent position, and 80/60 when standing. The pulse rate varied from 60 per minute to 62. The patient was alert. The alternating Horner sign was observed, and a paucity of facial movements was visible. His speech was slow and monotonous. Muscle tone was increased bilaterally. There was incoordination. A laboratory examination revealed reduced serum sodium levels of 127 mEq/L and increased sodium excretion with plasma hypoosmolality (262 mOsm/kg/H), urine hyperosmolality and low serum renin activity (0.2 ng/ml/h). Renal functions were normal and the levels of adrenocortical and thyroid hormones were normal. There were no abnormalities observed in the chest roentgenogram taken. The level of antidiuretic hormone (ADH) was unreasonably high (5.74 pg/ml). A water-load test demonstrated failure of both water diuresis and inhibition of ADH secretion. These data suggested that hyponatremia in this case was caused by SIADH. The correlation between plasma osmolality and the concentration of ADH suggested that osmolality that initiates ADH release appeared to have been reset to around 230 mOsm/kg lower than normal.(ABSTRACT TRUNCATED AT 250 WORDS)

[Acute posterior interosseous nerve paralysis with constrictions possibly due to twists in the nerve trunk]

This report is concerning a case of acute spontaneous paralysis of the posterior interosseous nerve (P.I.O.N.), possibly caused by twists in the nerve trunk, in a 23-year-old woman. The subject felt a tingling pain over the lateral epicondyle of the right forearm when grasping and lifting a basin, and noticed that the fingers of the right hand could not be extended three days later. The fingers of the left hand also experienced paralysis 3 months after the first injury when she pronated and extended left forearm. Neurological examination revealed bilateral P.I.O.N. paralysis. When, after a period of time, the bilateral P.I.O.N. paralysis had not improved, surgical exploration of both P.I.O.N. was performed. It revealed that the right P.I.O.N. underwent a severe constriction at 2 cm proximal to the superficial portion of the supinator muscle, and that the proximal portion of the right nerve was swollen. The constricted portion of the right nerve was resected 5 mm in length, and nerve suturing was performed. The left P.I.O.N. was also constricted at the same location, and was found to be a sausage-like neurinoma with two constrictions. In the histological examination of the right resected P.I.O.N., edema of the interstitial tissue and a great number of regenerating cluster formations, including swollen axons, were observed proximal to the constriction. Distal to this, severe Wallerian degeneration was found. These histological findings were the same as those of chronic compression neuropathy. The authors reviewed and analysed reports on 20 other cases of P.I.O.N. paralysis that had compressions at 2 cm proximal to the superficial portion of the supinator muscle.(ABSTRACT TRUNCATED AT 250 WORDS)

[Chronic inflammatory demyelinating polyradiculoneuropathy presenting localized radiculopathy as an initial symptom]

We reported a patient with chronic inflammatory demyelinating polyradiculoneuropathy (CIDP), presenting localized radiculopathy as an initial symptom. The patient, a 38-year-old man, developed muscle atrophy of right shin and calf. In April 1988, neurological examination revealed decreased superficial sensation and muscle atrophy in right L-4 distribution. MRI of the lumbar spinal cord and myelography were negative. In April 1989, he was admitted to Chiba University Hospital. There were slight weakness of right ankle extension and flexion, muscle atrophy of bilateral shin and calf (that of the right leg was more marked), decreased sensation of polyneuropathy type in all modalities and generalized hypo- or a-reflexia. Nerve conduction study revealed marked prolongation of F response and focal conduction block in various site. The CSF was acellular and total protein was 177 mg/dl. Sural nerve biopsy disclosed decreased number of large myelinated fibers and scattered thin myelinated fibers. This case indicates that CIDP may present localized radiculopathy in early phase and is important to point out various mode of onset among CIDP.

Squamous cell carcinoma antigen in oral squamous cell carcinomas

Squamous cell carcinoma (SCC) antigen is a tumor-associated antigen isolated from the squamous cell carcinoma of the uterine cervix. In order to estimate the usefulness of the SCC antigen in monitoring the clinical behaviors of oral squamous cell carcinomas, we analyzed clinicopathologically and immunohistochemically 54 cases of squamous cell carcinoma of the oral cavity. Elevated serum SCC antigen levels were detected in 23 (42.6%) out of 54 oral squamous cell carcinomas. The positive rate of serum SCC antigen levels was significantly higher in the patients with advanced clinical stages and poorly differentiated carcinoma. The serum levels declined rapidly after the surgical operation. It is considered that the serum SCC antigen levels could be useful in monitoring the extension, effectiveness of therapy, recurrence and metastases of the oral squamous cell carcinomas. Immunohistochemically, strong staining was seen in the cytoplasm of the well-differentiated carcinoma cells.

["Acro-erythro-cyanosis"--peculiar vasomotor symptoms due to cervical hernial myelopathy]

Two cases of cervical myelopathy, which exhibited peculiar vasomotor symptoms ("acro-erythro-cyanosis") on distal regions of the four limbs are reported. Continuous reddening, swelling and skin temperature increase were observed on both hands and feet in case 1, a-44-year-old man, and on both hands in case 2, a-47-year-old man. Cold stimulation resulted in cyanosis and decrease of skin temperature on the affected regions paroxysmally. The condition of skin at room temperature may be caused by arteriectasia of arterioles due to hypotonia of vasomotor fibers, and this was similar to erythromelalgia. On the other hand, cold stimulation may have led to this condition, where the contraction of skin arterioles due to hypertonia of vasomotor fibers was added to the dilation of venule, and this was similar to acrocyanosis. Consequently, we provisionally named the vasomotor symptoms in the present cases as "acro-erythro-cyanosis". The other neurological signs were as follows. Case 1: mild weakness in right upper and lower limbs and left small hand muscles, mild superficial and deep sensory disturbance on bilateral palms and soles and decrease of vibration on bilateral lumbar regions and thereunder. Case 2: mild weakness of right small hand muscles, superficial sensory disturbance on distal regions of bilateral upper and lower limbs and a decrease of joint position sense on right hand. Myelography and metrizamide CT myelography revealed a high-degree deformity of the spinal cord due to the herniated disks between C4 and C5 in case 1 and between C3 and C4 in case 2.(ABSTRACT TRUNCATED AT 250 WORDS)

[EDTA-dependent pseudothrombocytopenia in association with myasthenia gravis]

Ethylenediaminetetraacetate (EDTA)-dependent pseudothrombocytopenia, in vitro platelet clumping and consequent pseudothrombocytopenia in the presence of EDTA, was observed in a patient with thymoma-associated myasthenia gravis (MG). The patient, a 45-year-old man, presented with alopecia areata, and weakness and fatigue of right upper extremity and neck muscles. Diagnosis of MG was made on the basis of positive edrophonium test and antiacetylcholine receptor (AChR) antibody test. The platelet count was as low as 4.9 X 10(4)/mm3 in EDTA-anticoagulated blood and large agglutinates were seen in smears from EDTA blood. Platelet suspension immunofluorescence test showed IgG on the surface of platelet clumping. Corticosteroid therapy combined with thymectomy reduced the platelet clumping markedly in parallel with decrease of anti-AChR antibody titers. The present observation suggests that EDTA-dependent pseudothrombocytopenia in our patient was associated with some immunological abnormalities. Recognition of the pseudothrombocytopenia in MG patients is important to distinguish it from idiopathic thrombocytopenia purpura which is also found in MG and requires bone marrow tests and sometimes splenectomies.

Studies on monocyclic beta-lactam antibiotics. II. Synthesis and antibacterial activity of 3-acylamino-2-azetidinone-1-oxysulfonic acids

The synthesis and in vitro antibacterial and beta-lactamase inhibitory activity of the 2-azetidinone-1-oxysulfonic acids having a substituent at C-4 position of the beta-lactam ring are described. The influence of C-4 substituents on the antibacterial activity was examined for the compounds having alpha-ureidoacetyl or alpha-oxyiminoacetyl group as acyl side chain at C-3 position. The antibacterial activity is correlated with the C-4 substituents and acyl side chain. Especially, 4(R)-methyl substituted derivatives exhibited excellent activity against Gram-negative bacteria and 4-dimethyl substituted derivatives exhibited strong activity against resistant Gram-negative bacteria except for Pseudomonas aeruginosa. 39 and 40 showed strong inhibitory activity against cephalosporinase of Enterobacter cloacae H-27.