The clinical impact of the ratio of C-reactive protein to albumin (CAR) in patients with acute- and lymphoma-type adult T-cell leukemia-lymphoma (ATL)

Recently, the ratio of C-reactive protein to albumin (CAR) is used as an inflammatory marker that has been demonstrated to be a simple and reliable prognostic factor in solid tumors and hematological malignancy. However, no studies of the CAR have been performed in patients with adult T-cell leukemia-lymphoma (ATL). We retrospectively analyzed the clinical features and outcomes in 68 newly diagnosed acute- and lymphoma-type ATL [(acute-(n=42) or lymphoma-type (n=26)] patients in Miyazaki Prefecture from 2013 to 2017. Furthermore, we investigated correlations between pretreatment CAR levels and clinical features. The median age was 67 years (range, 44 - 87). Patients were initially treated by either palliative therapy (n=14) or chemotherapy [n=54; CHOP therapy (n=37)/ VCAP-AMP-VECP therapy (n=17)], and showed median survival durations of 0.5 months and 7.4 months, respectively. The factors affecting OS by multivariate analysis were age, BUN, and CAR. Importantly, we revealed that the high CAR group (optimal cut-off point; 0.553) was a significant indicator of worse OS by multivariate analysis (p< 0.001, HR; 5.46). The median survival of patients with a CAR< 0.553 was 8.37 months, while patients with a CAR>0.553 had a median survival of 3.94 months. The different clinical features between high CAR and low CAR groups were hypoproteinemia and the implementation of chemotherapy. Furthermore, in the chemotherapy group, but not the palliative therapy group, CAR was a significant prognostic marker. Our study indicated that CAR may be a new simple and significant independent prognostic marker in acute- and lymphoma-type ATL patients.

Secondary Skin Cancer in a Case with Long-term Voriconazole after Allogeneic Hematopoietic Stem Cell Transplantation for Acute Myeloid Leukemia

Secondary malignancies that develop after allogeneic-hematopoietic stem cell transplantation (allo-HSCT) have become serious issues. A 47-year-old man who developed acute myeloid leukemia in 2009 and subsequently underwent allo-HSCT twice: in 2009 and 2011. In 2015, voriconazole for lung aspergillus was started. In 2018, chronic graft-versus-host disease (GVHD) and multiple actinic keratoses manifested at his head. In 2020, some lesions were diagnosed as squamous cell carcinoma, so voriconazole was withdrawn, and subsequent surgery and radiation led to remission. Long-term administration of voriconazole in addition to allo-HSCT and chronic GVHD may be closely related to secondary skin cancer.

Clinical features and outcomes of four atypical hemolytic uremic syndrome cases at a single institution in Miyazaki Prefecture from 2015 to 2019

Background

Although atypical hemolytic uremic syndrome (aHUS) is a life-threatening clinical entity that was characterized by thrombotic microangiopathy (TMA) with the activation of the complement system and the efficient treatment of eculizumab, the clinical features of aHUS have been unclear because of the rare incidence.

Case presentation

We retrospectively analyzed 4 aHUS cases at a single institution during 2015–2019. Here, we presented 4 aHUS cases with renal transplantation (one case), influenza/acute interstitial pneumonia/disseminated intravascular coagulation (two cases), and severe fever with thrombocytopenia syndrome (one case), respectively. Initial clinical symptoms were microangiopathic hemolytic anemia (four cases), renal dysfunction (four cases), thrombocytopenia (four cases), and pulmonary hemorrhage (three cases) consisted with TMA features. Subsequent further examinations ruled out thrombotic thrombocytopenic purpura, Shiga toxin-producing E.coli-induced hemolytic uremic syndrome, and secondary TMA. Taken these findings together, we made the clinical diagnosis of aHUS. Furthermore, all cases also presented the high levels of plasma soluble C5b-9 (871.1 ng/ml, 1144.3 ng/ml, 929.2 ng/ml, and 337.5 ng/ml), suggesting persistent activation of complementary system. Regarding the treatment, plasma exchange (PE) (four cases) and eculizumab (two cases) therapy were administered for aHUS cases. Consequently, case 2 and case 4 were still alive with 768 days and 235 days, respectively. The other two cases were dead at 34 days and 13 days, respectively. Finally, although the previous reported genetic pathogenetic mutations were not detected in our cases, multiple genetic variants of complement factors were detected as CFH (H402Y, E936D), and THBD (A473V) in case 1, CFH (V62I, H402Y, V837I) in case 2, and CFH (H402Y, E 936D) and THBD (A473V) in case 3, CFH (V62I, H402Y, E936D) and THBD (473V) in case 4, respectively.

Conclusions

Because of still high mortality in our study, an urgent diagnosis of aHUS and subsequent immediate treatment including PE and eculizumab should be essential in clinical practice. Furthermore, the multiple genetic variants and the triggers may be related to one of the pathogenesis of aHUS. Thus, we assume that such a case-oriented study would be highly useful to the physicians who directly care for aHUS cases in clinical practice.

Serial evaluation of the pharmacokinetics of ponatinib in patients with CML and Ph + ALL

Although tyrosine kinase inhibitors (TKIs) play a crucial role in the treatment of chronic myeloid leukemia (CML) and Philadelphia chromosome-positive acute lymphoblastic leukemia (Ph + ALL), intolerance and resistance to TKIs have been serious problems. Due to a lack of research, the importance of the pharmacokinetics (PK) of TKIs is currently unclear. We examined the PK of the third-generation TKI ponatinib to monitor side effects and efficacy during treatments for one patient with CML-chronic phase (CP-CML) and two who received allogeneic hematopoietic stem cell transplantation (allo-HSCT), one for CML-blastic crisis (BC-CML) and one for Ph + ALL. The patient with CP-CML was intolerant to multiple TKIs (dasatinib, nilotinib, imatinib, and bosutinib) and thus was switched to ponatinib (15 mg/day). The patients who received allo-HSCT for BC-CML and Ph + ALL received ponatinib (15 mg/day) as maintenance therapy. Notably, serial evaluation of the PK of ponatinib showed that the median trough values (ng/ml) were 17.2 (12.2-34.5), 33.1 (21.2-40.3) and 27.7 (13.6-29.9) in patients 1, 2, and 3, respectively. These values were around the target concentration (23 ng/ml). All patients are maintaining complete remission without side effects. In conclusion, serial evaluation of PK of ponatinib may yield meaningful information about its safety and efficacy.

Uterine relapse of Philadelphia chromosome-negative acute lymphoblastic leukemia

The relapse of acute lymphoblastic leukemia (ALL) usually involves the bone marrow, with the central nervous system being the most frequent extramedullary site. The relapse of ALL in the female genital organs, particularly the uterus, is markedly rare. We report such a patient who developed relapse in the bone marrow and uterus. The uterine lesion, which presented as abnormal uterine bleeding, consisted of a mass on MRI and proliferation of ALL cells on histology. MRI revealed a heterogeneous high-intensity mass (T2-WI/D-WI) with a diameter of 6.8 cm, a notable decrease in the apparent diffusion coefficient (ADC), and mild enhancement by contrast enhancement study. Histological findings of the uterine cervix demonstrated the infiltration of ALL. The patient achieved remission by allogeneic haplo-identical hematopoietic stem-cell transplantation, but died of complications of the transplantation. This case suggested that attention should be paid to the uterus as a site of extramedullary relapse. In addition, abnormal uterine bleeding, which is a common sign of hormonal imbalance and hormone replacement therapy after chemotherapy, may be an initial sign of extramedullary recurrence. To confirm uterine relapse as an intractable disease, the accumulation of more cases is required.

Pharmacokinetics of anti-thymocyte globulin in a patient with severe aplastic anemia treated with allogeneic bone marrow transplantation from a matched unrelated donor

Anti-thymocyte globulin (ATG) is an important component of preparative regimens for allogeneic bone marrow transplantation (BMT) for aplastic anemia (AA). However, the pharmacokinetics (PK) of ATG are unclear. A 38-year-old woman with severe AA underwent BMT using a fludarabine (Flu)-based and reduced-dose cyclophosphamide (CPA)-conditioning regimen comprising rabbit ATG (2.5 mg/kg, days -7 and -6), Flu (30 mg/sqm, days -5 to -2), CPA (25 mg/kg, days -5 to -2), and total body irradiation (2 Gy, day -1), following a human leukocyte antigen-match with an unrelated donor. Notably, ATG was administered earlier than that recommended by conventional schedules. The engraftment was achieved on day 15 without reactivation of the Epstein-Barr virus and residual recipient cells. Absolute lymphocyte recovery (>0.5×10⁹/L) was achieved on day 22. The ATG concentration on day 0 and the area under the concentration-time curve (AUC) for ATG after allogeneic BMT were 21.8 μg/mL and 464 μg・day/mL, respectively. The patient remained disease-free for 6 years after BMT without acute or chronic graft-versus-host disease. Moreover, based on serum PK monitoring of ATG, including ATG concentration on day 0 and the AUC for ATG after BMT, the patient safely underwent the less-toxic, Flu-based, reduced-dose CPA regimen containing a low dose of ATG. In conclusion, we present the first report that analyzed the PK of ATG in a patient with AA treated with BMT from a matched unrelated donor. These findings might be helpful to determine ATG dosages for such patients receiving similar transplantations.

Three cases of late-onset anthracycline-related cardiomyopathy due to chemotherapies for hematological malignancy

BACKGROUND

Although anthracycline-related cardiomyopathy is a life-threatening complication during intensive treatment for hematological malignancies, clinical features and outcomes of this type of cardiomyopathy have been unclear because of limited reports in the literature.

METHODS

We analyzed three cases of anthracycline-related cardiomyopathy among 996 patients with either acute myelogenous leukemia (285), acute lymphoblastic leukemia (37), or malignant lymphoma (674) at our hospital during the period from 2006 to 2016.

RESULTS

All patients showed accumulation of anthracycline within a proper range (< 500 mg/sqm). Two patients (Hodgkin lymphoma and acute lymphoblastic leukemia) showed acute heart failure (AHF) with ejection fraction (EF) of 30 and 40% after 4.5 and 5 years after diagnosis, respectively. For AHF, diuretics and carperitide were administered to control in-out balance. The remaining patient (follicular lymphoma) showed ventricular fibrillation (VF)/ventricular tachycardia (VT) with EF of 40% at 5 years after diagnosis. In this patient, immediate cardioversion made VF/VT to normal sinus rhythm, and then, amiodarone was given. Furthermore, implantable cardioverter defibrillator was set up for VF/VT. In all patients, β blocker and/or angiotensin-converting enzyme inhibitor (ACE-I) were administrated to prevent recurrence of anthracycline-related cardiomyopathy. Consequently, two of three patients showed mild improvement of cardiac function.

CONCLUSION

Our study indicates that late-onset (4 to 5 years) anthracycline-related cardiomyopathy can develop, though range of anthracycline accumulation is in proper range. Thus, a cautious follow-up by ECG and UCG is required. Furthermore, the early treatment after the onset of anthracycline-related cardiomyopathy should be also needed to improve the poor outcome.

Clinical features and treatment outcomes of opportunistic infections among human T-lymphotrophic virus type 1 (HTLV-1) carriers and patients with adult T-cell leukemia-lymphoma (ATL) at a single institution from 2006 to 2016

As opportunistic infections among human T-lymphotrophic virus type 1 (HTLV-1) carriers and patients with adult T-cell leukemia/lymphoma (ATL) pose a serious problem, it is necessary to clarify their clinical characteristics and outcomes in these patients. We retrospectively analyzed the clinical features and outcomes of opportunistic infections in 127 HTLV-1 carriers and 153 ATL patients between 2006 and 2016. The cumulative incidence rates of opportunistic infections among HTLV-1 carriers and ATL patients were 1.5% (2/127) and 6.5% (10/153), respectively. The etiology of opportunistic infections was as follows: fungal infections (3 cases), pneumocystis pneumonia, and cytomegalovirus (CMV) infections. Even after aggressive treatment, the prognosis of opportunistic infections was poor (50% of overall survival at 28 days). Regarding prognostic factors affecting the OS of opportunistic infections, higher SOFA scores (especially the respiratory subscore) and higher LDH values were identified by univariate analysis. Moreover, 3 out of 6 patients achieved spontaneous remission of ATL as the short-term outcome after the development of opportunistic infection. However, 5 out of 6 surviving patients exhibited ATL progression or relapse after a median of 194 days (133-226) after contracting an opportunistic infection as the long-term outcome of ATL. In conclusion, opportunistic infections should be carefully followed among HTLV-1 carriers and ATL patients because of their aggressive clinical course and poor outcomes. Furthermore, early diagnosis and subsequent prompt treatment are necessary in clinical practice.

Clinical Features, Pathological Features, and Treatment Outcomes of 22 Patients with Aggressive Adult T-cell Leukemia-lymphoma Treated with a Humanized CCR4 Antibody (Mogamulizumab) at a Single Institution during a 6-year Period (2012-2018)

Objective To elucidate the clinical impact of humanized CCR4 antibody (mogamulizumab) on adult T-cell leukemia-lymphoma (ATL), we retrospectively analyzed the clinical and pathological features and treatment outcomes of aggressive ATL. Methods Twenty-two patients (median age: 65 years) with aggressive ATL [acute- (n=16) or lymphoma-type (n=6)] had their characteristics analyzed. All cases were treated with mogamulizumab at our institution from 2012 to 2018. In addition, we subjected 14 specimens of ATL to histological, immunological, and genetic analyses. Results Regarding the patient outcomes, the overall response rates were 68.1% and 31.8% after 4 and 8 courses (or after the final courses), respectively. The median overall survival (OS) was 95.5 days, while the OS rates at 6 and 12 months were 31.5% and 21.1%, respectively. Concerning patient pathological characteristics, 6 of the 14 patients examined (42.9%) had CCR4 mutations. Regarding the clinicopathological findings related to the mogamulizumab response, notably, the cases with somatic CCR4 mutation tended to have a poorer response (16.7%) than those with wild-type CCR4 (62.5%) after 4 cycles of mogamulizumab. Furthermore, the CCR4 global score tended to be higher in the responder cases than in the non-responder cases. Conclusion The present findings suggest that the CCR4 expression may be related to the mogamulizumab response, although no other significant predictive markers were identified in this study. Further studies will be needed in order to identify more markers related to the mogamulizumab response.

[In vitro susceptibilities to levofloxacin and various antibacterial agents of 12,919 clinical isolates obtained from 72 centers in 2007]

We have reported in this journal in vitro susceptibilities of clinical isolates to antibiotics every year since 1992. In this paper, we report the results of an analysis of in vitro susceptibilities of 12,919 clinical isolates from 72 centers in Japan to selected antibiotics in 2007 compared with the results from previous years. The common respiratory pathogens, Streptococcus pyogenes, Streptococcus pneumoniae, Moraxella catarrhalis and Haemophilus influenzae maintained a high susceptibility to fluoroquinolones (FQs). The resistance of S. pyogenes to macrolides has been increasing every year and this was especially clear this year. Most strains of Enterobacteriaceae except for Escherichia coli showed a high susceptibility to FQs. Almost 30% of E. coli strains were resistant to FQs and the resistance increased further this year. FQs resistance of methicillin-resistant Staphylococcus aureus (MRSA) was approximately 95% with the exception of 45% for sitafloxacin (STFX). FQs resistance of methicillin-susceptible S. aureus (MSSA) was low at about 10%. FQs resistance of methicillin-resistant coagulase negative Staphylococci (MRCNS) was higher than that of methicillin-susceptible coagulase negative Staphylococci (MSCNS), but it was lower than that of MRSA. However, FQs resistance of MSCNS was higher than that of MSSA. FQs resistance of Enterococcus faecalis was 22.5% to 29.6%, while that of Enterococcusfaecium was more than 85% except for STFX (58.3%). In clinical isolates of Pseudomonas aeruginosa derived from urinary tract infections, FQs resistance was 21-27%, which was higher than that of P. aeruginosa from respiratory tract infections at 13-21%, which was the same trend as in past years. Multidrug resistant strains accounted for 5.6% in the urinary tract and 1.8% in the respiratory tract. Acinetobacter spp. showed high susceptibility to FQs. The carbapenem resistant strains, which present a problem at present, accounted for 2.7%. Neisseria gonorrhoeae showed high resistance of 86-88% to FQs. The results of the present survey indicated that although methicillin-resistant Staphylococci, Enterococci, E. coli, P. aeruginosa, and N. gonorrhoeae showed resistance tendencies, and other species maintained high susceptibility rates more than 90% against FQs, which have been used clinically for over 15 years.

Clinical comparison of the scanning CO2 laser and conventional surgery in the treatment of ingrown nail deformities

AIM

To compare statistically the clinical effects and postoperative course of the scanning CO(2) laser and conventional surgical method to evaluate the clinical effectiveness of the former for the treatment of ingrown nail deformities.

METHODS

We performed vaporization of the nail matrix using the scanning CO(2) laser in 25 cases with ingrown nail deformities.

RESULTS

In 21 cases, the recurrence of ingrown nail deformity was not observed during follow-up. All cases were free of postoperative infection. Use of the scanning CO(2) laser reduced postoperative pain, and all patients were able to return to their daily activities by day 3 post-surgery without any problems.

CONCLUSIONS

Statistically, the operating time and the duration of postoperative pain were reduced significantly by the scanning CO(2) laser. Furthermore, patients treated with CO(2) laser were able to return to daily life significantly sooner.

Experience with surgical treatment of hidradenitis suppurativa

The authors report their experience with 23 sites of hidradenitis suppurativa, including cases with musculocutaneous flap repair, and discuss the surgical methods applied. Twenty-three sites in 19 patients with chronic inflammatory skin lesions were reviewed. The lesions were divided into two groups: The limited group was comprised of mild lesions, which appear isolated and have limited abscesses without sinus tract formations. The severe group was compromised of severe lesions, which included diffuse, multiple abscesses with severe sinus tract formation and fibrosis. Nine sites were limited and 14 sites were severe. After resecting the lesion, the defect was covered with a split-thickness skin graft (four sites were limited, nine sites severe), a musculocutaneous flap (five sites severe), primary closure (four sites limited), and a local skin flap (one site limited). In six sites in 6 severe-group patients, local recurrence occurred. The local recurrence rate differed significantly between the limited and the severe groups. The reason for this may be because the lesions in the limited group could be resected completely, whereas the lesions in the severe group were diffuse and total resection was sometimes difficult for various reasons. The method of surgical repair did not affect the local recurrence rate. In recurrent cases, four sites treated with skin grafting required further surgical treatment, and two sites treated with musculocutaneous flaps were controlled with oral antibiotics. In conclusion, sufficient resection of the lesion is the most important issue in treating follicular occlusion triad disease. In lesions that can be resected completely, the surgical procedure to cover the lesions should be selected to suit the size and site of the defect. However, in cases that cannot be resected completely, a musculocutaneous flap is recommended instead of a skin graft for enhanced postoperative management of the recurring wound, and its contribution to aesthetic and functional improvement.

The difference in E-cadherin expression between nonvascularized and vascularized nerve grafts: study in the rat sciatic nerve model

BACKGROUND

We investigated the expression of E-cadherin during nerve regeneration after nonvascularized and vascularized nerve grafts.

MATERIALS AND METHODS

We used the rat sciatic nerve model. E-cadherin expression was detected by Western blot analysis and immunofluorescent staining with anti E-cadherin monoclonal antibody. The level of E-cadherin expression was calculated as the amount relative to that of E-cadherin expression of normal control nerve. Furthermore, repair of the neural tissue structure was examined by toluidine blue staining.

RESULTS

In both cases, the level of E-cadherin expression decreased at first, and then gradually increased. The maximum level was 1.61 +/- 0.066-fold in the nonvascularized nerve graft and 2.254 +/- 0.071-fold in the vascularized nerve graft. From the 1st to the 16th postoperative weeks, the level of E-cadherin expression in the vascularized nerve graft was significantly higher than that in the nonvascularized nerve graft. In the immunofluorescent staining, E-cadherin expression was almost negative or decreased immediately after the operation, but the degree of expression was gradually increased in Schwann cells. The degree of E-cadherin expression in the vascularized nerve graft was greater than that in the nonvascularized nerve graft. In toluidine blue staining, the velocity of tissue repair was more rapid in the vascularized nerve graft than in the nonvascularized graft.

CONCLUSION

These results demonstrate that the E-cadherin expression of grafted nerve was increased during the nerve regeneration, and the expression was mainly observed in Schwann cells. Because the level of E-cadherin expression was significantly higher in the vascularized nerve graft than in the nonvascularized nerve graft, the level of E-cadherin expression may affect the rapidity of nerve regeneration.

Detection of E-cadherin expression after nerve repair in a rat sciatic nerve model

The authors investigated E-cadherin expression during nerve regeneration after nerve suture using the rat sciatic nerve model. Five rats were used during each postoperative period. E-cadherin expression was detected by Western blot analysis and immunofluorescent staining with an anti-E-cadherin monoclonal antibody. The level of E-cadherin expression was calculated as the amount relative to that found in normal control nerve. The level of E-cadherin expression was decreased at first, and then gradually increased. The maximum level of E-cadherin was 1.92 +/- 0.07 fold in the sutured nerve. The level of E-cadherin expression in the sutured nerve was significantly greater (p < 0.0001) than that of the normal control nerve from postoperative day 3 to 21, and that of sutured nerve returned to the control level by postoperative day 28. The immunofluorescent staining results indicated that E-cadherin expression was almost negative or decreased immediately after the operation, but the degree of expression increased gradually in Schwann's cells. The degree of E-cadherin expression was significantly greater than that of normal control nerves from postoperative day 7 to 14, and returned to the control level by postoperative day 21. These results demonstrate that E-cadherin expression increases during nerve regeneration, and the expression was observed mainly in Schwann's cells. The degree of E-cadherin expression may affect the rate of nerve regeneration.

Lip reconstruction of comparatively large defect including the commissure using remaining lip tissue: a modification of reconstructed method

We present two reconstructed cases after malignant skin tumor of comparatively large defects of lip including the commissure using remaining lip tissue alone. After resecting a tumor including wedge-shaped full-thickness lip tissue, a full thickness oblique incision is made at the site 5 mm distant from the contralateral commissure. The rhomboid-shaped lower lip flap is created, transposed to the defect, and sutured with the defect margin, including the upper lip, to reconstruct the commissure. The cross lip flap is created at the contralateral side of the lower lip, 5 mm from the commissure, and the defect is closed with the crosslip flap. Although our method is applicable only to selected cases, we believe that it is useful in terms of maintaining symmetry of the lip and function of the commissure in the reconstruction of comparatively large defects including the commissure.

Application of artificial dermis graft to correct a depression after tissue resection

The authors present 7 cases of artificial dermis implantation to correct a depression after tissue resection. Four of the seven cases resulted from resection of a malignant tumor (N = 3) and from a benign subcutaneous tumor (N = 1). The other 3 cases were the result of temporal muscle harvest to reconstruct facial palsy. In 1 patient a mild degree of bone deformity also existed. The pieces of artificial dermis employed varied from 35 x 40 to 40 x 80 mm in size. In 5 patients two sheets were implanted, and in 2 patients three sheets were implanted. In 2 patients the dermis sheets were covered by a pedicled temporal fascial flap with a free split-thickness skin graft because whole skin was resected as a result of a malignant skin tumor. There was no postoperative infection or allergic reaction in any of the patients. In all cases there was no postoperative contracture, and the implanted area was soft. An adequate or acceptable thickness of subcutaneous tissue was obtained. Artificial dermis may be a useful option as implantation material to correct a depression after tissue resection, especially for wide and comparatively shallow depressions.

Alteration of the cellular response to interleukin-1 beta by SV40 large T antigen in rheumatoid synovial fibroblasts

The large T antigen of SV40 (LT) has been widely used to immortalize primary cells for various studies. In this study, synovial fibroblasts of a patient from rheumatoid arthritis (RA) were transformed with LT gene to analyze the effect of SV40-mediated transformation on the production of cytokines, such as IL-6, IL-8, and GM-CSF, that are under the control of interleukin-1 beta (IL-1 beta), a physiological inducer of nuclear factor kappa B (NF-kappa B). It was noted that the basal levels of GM-CSF and IL-8 were upregulated, whereas that of IL-6 was downregulated. Moreover, the extents of induction of these cytokines in response to IL-1 beta were markedly downregulated in synovial fibroblasts transformed by LT as compared from parental cells. Although IL-1 beta could translocate NF-kappa B to the nucleus in all cells, some of the transformed cells exhibited nuclear translocation of NF-kappa B even before the stimulation with IL-1 beta, suggesting that transformation of LT resulted in the constitutive activation of NF-kappa B, either directly or indirectly. In order to examine whether LT downregulate the kappa B-dependent gene expression, we performed the transient luciferase gene expression assay. We found that cotransfection of LT did not downregulate the kappa B-dependent gene expression that was stimulated with L-1 beta. These observations suggest that the apparent inhibitory effect of LT on the IL-1-induced expression of cytokines may not be through its direct action on the NF-kappa B transactivation.

Involvement of vascular endothelial growth factor in Kaposi's sarcoma associated with acquired immunodeficiency syndrome

To examine the role of vascular endothelial growth factor (VEGF) in the development of edema associated with Kaposi's sarcoma (KS) in acquired immunodeficiency syndrome (AIDS), we exploited animal model systems to detect the activity that induces vascular hyper-permeability (VHP) using cultured AIDS-KS spindle cells. Cultured AIDS-KS spindle cells and conditioned medium (AIDS-KS-CM) that had been semi-purified through a heparin affinity column were tested for the ability to induce VHP in animals. The AIDS-KS spindle cells and AIDS-KS-CM induced VHP that was histamine-independent. The VHP-inducing activity was detected in the 0.5 M NaCl fraction from the heparin affinity column and was blocked by anti-VEGF neutralizing antibody. In addition, the production of VEGF was demonstrated in fresh AIDS-KS tissue as well as in cultured AIDS-KS cells, while control cells were negative for VEGF production. From these observations, we concluded that AIDS-KS cells produce a factor(s) that promotes VHP, and this factor could be VEGF.

[Mechanism of poor responsiveness to therapy of bacterial infection in patients with connective tissue diseases]

Infectious complications are important factors for poor prognosis of connective tissue diseases (CTD). 33% of the fatal cases with CTD were caused by infectious complications in our study. It was characteristic of infectious complications with CTD, that pneumonia was recognized in all CTD, especially, commoner in PSS, PM and OL, and frequently caused a fatal outcome. Gram negative bacillus, for instance E. coli and K. pneumoniae were frequently detected as pathogens. On the other hand, methicillin resistant Staphylococcus aureus (MRSA) was increased recently, and tuberculosis, especially atypical tuberculosis, such as, miliary and cutaneous forms were also recognized. The risk factors in the development of bacterial infections is considered to be intricately correlated with cellular and humoral immunodeficiency due to CTD or steroid hormones.

[A case of Legionnaires' disease due to aspiration of hot spring water and isolation of Legionella pneumophila from hot spring water]

We report a case of fulminant pneumonia that was due to aspiration of contaminated hot spring water and was not affected by beta-lactam antibiotics. We suspected that the patient had Legionnaires' disease and treated the clinical symptoms with erythromycin. Legionellaceae could not be isolated from sputum or lung biopsy material, but an elevated titer to Legionella pneumophila serogroup 4 was found by indirect immunofluorescence test. We diagnosed the patent as having Legionnaires' disease with improved clinical symptoms. Furthermore, we went to the hot spring that he visited and tried to isolate Legionellaceae. Hot spring water was collected from the bathroom and water, hot water, and shower water from the guest-room. After using a low-pH method, samples were cultured on BCYE alpha medium. Serogroups are classified by agglutination method with immune rabbit serum. As a result, we successfully isolated Legionella pneumophila serogroup 4 from hot spring water (42 degrees C) from the bath. No bacteria could be isolated from the other samples. Therefore, we believe that this case of Legionnaires' disease was caused by aspiration of contaminated hot spring water. The infection route of Legionnaires' disease is unclear. There are no previous reports of isolation of Legionellaceae from Japanese hot springs. This case would provide important information when considering the infection route of Legionnaires' disease in Japan.