A case of systemic lupus erythematosus in a patient with Noonan syndrome with recurrent severe hypoglycemia

Noonan syndrome (NS) is a dominantly inherited genetic disorder with mutations in genes encoding components or regulators of the RAS/mitogen-activated protein kinase pathway. Its diagnosis is based on characteristic features, including typical facial features, a short stature, congenital heart disease, mild developmental delay, and cryptorchidism. Patients with NS sometimes develop autoimmune diseases, such as Hashimoto's thyroiditis and, rarely, systemic lupus erythematosus (SLE). We herein present a 29-year-old Japanese female with NS complicated by SLE and repeated severe hypoglycemia. The patient was diagnosed with SLE based on thrombocytopenia, nephritis, a positive antinuclear antibody titer (1:640), and a positive anti-dsDNA antibody. The patient was treated with a glucocorticoid, mycophenolate mofetil, and tacrolimus, which attenuated both SLE and hypoglycemia. Since insulin receptor antibody levels were higher to the upper normal range and decreased after treatment, hypoglycemia probably appeared to be attributed to type B insulin resistance syndrome (TBIRS). We herein present the first case of SLE in NS complicated by TBIRS. Although NS is a rare disease, we need to consider the complication of autoimmune diseases, including SLE.

A murine model of communicating hydrocephalus: Role of TGF-beta1

Subarachnoid haemorrhage (SAH) often causes communicating hydrocephalus. We recently found that intrathecal injection of human recombinant transforming growth factor (hrTGF)-beta1 induced communicating hydrocephalus in mice. In this experiment we examined whether hydrocephalus could be generated in mice by intrathecal injection of autologous serum, which would contain TGF-beta1 in a similar situation to SAH. Mouse serum, plasma and a range of quantities of hrTGF-beta1 were injected intrathecally into 10 day old C57BL/6 mice. The sizes of the lateral ventricles were measured some weeks after injection. The serum induced hydrocephalus which was prevented by additional injection of anti-TGF-beta1 antibody. Immunoblot analysis showed a band of the active form of TGF-beta1 in the serum which was not detected in the plasma. This study therefore suggests that active TGF-beta1 in cerebrospinal fluid after SAH contributes to the generation of communicating hydrocephalus.

Induction of communicating hydrocephalus in mice by intrathecal injection of human recombinant transforming growth factor-beta 1

Transforming growth factor-beta 1 (TGF-beta 1) is a multi-functional polypeptide, which controls proliferation, differentiation of various cells, and regulates synthesis of extracellular matrix proteins. We injected human recombinant TGF-beta 1 into the subarachnoid space of 10-day-old C57BL/6 mice in order to study the role of TGF-beta 1, which is known to be released from platelets into the cerebrospinal fluid following subarachnoid hemorrhage. The ventricular system became dilated within 3 weeks following the injection and the body weights of injected mice stopped increasing 6 weeks after injection of TGF-beta 1. Microscopic examination revealed dilatation of the ventricular system, and that the outlets of the ventricles were not obliterated. Electron microscopy showed diminution of cilia on the ependyma. These results demonstrate that TGF-beta 1 induces communicating hydrocephalus in mice. This hydrocephalic model should be useful in further studies on the pathogenesis of normal pressure hydrocephalus following subarachnoid hemorrhage in man.

Reconstruction of the anterior commissure with a free mucosal flap

INTRODUCTION

To prevent stenosis and adhesion of the anterior commissure in the laryngeal reconstruction, we devised a technique of relining using a free labial mucosal graft and human fibrin glue.

MATERIALS AND METHODS

A single large piece of mucosal flap was prepared, folded at the anterior commissure, and sutured onto the raw wound of the larynx from both sides of the posterior glottis. Alternate suturing from both right and left sides was performed anteriorly, and the wound on the laryngeal lumen was fully covered by the mucosal graft. We applied this technique on a patient with laryngeal stenosis and two patients with laryngeal cancer.

RESULTS

Without the use of a stent, we successfully reconstructed the anterior commissure and obtained a good result in voice quality in each case.

CONCLUSION

Large mucosal defects including the anterior commissure should be relined to acquire good voice quality. Relining using a free mucosal flap was a useful method since there were no limitations to size and placement. The adhesive property of human fibrin glue was indispensable in this procedure.

Remobilization of paralyzed vocal cord by anticus-lateralis muscle suturing

A new method of dynamic reconstruction by suturing the cricothyroid (anticus) and the lateral cricoarytenoid (lateralis) muscles was devised for the treatment of unilateral recurrent laryngeal nerve paralysis. Eighteen adult dogs underwent this surgical procedure after sectioning a recurrent laryngeal nerve. Immediate postoperative observations revealed a marked increase in tension of the paralyzed vocal cords and remobilization to the median line of 17 of 18 dogs. More than 4 months later, fiberscopic examination revealed a satisfactory adduction of the cords. Electrophysiologic and histologic examination showed reinnervation of the affected lateralis muscle by the external branch of the superior laryngeal nerve. The clinical applications of this surgery may serve as a dynamic reconstruction for unilateral recurrent laryngeal nerve paralysis.

Anticus-lateralis muscle suturing. Treatment of recurrent nerve paralysis

We have devised a new surgical method that sutures the cricothyroid (anticus) muscle to the paralyzed lateral cricoarytenoid (lateralis) muscle for the dynamic reconstruction of the larynx. Because this method achieved remobilization of the paralyzed vocal cord in dogs, we applied it to seven patients with unilateral recurrent laryngeal nerve paralysis (four patients had postsurgical paralysis and three patients had idiopathic paralysis). We obtained the following satisfactory results: (1) vocal cord tension and voice quality improved in all patients, and (2) in four patients, remobilization of the paralyzed vocal cord was obtained. We believe that this surgical method could serve as a new dynamic method of reconstruction for the treatment of unilateral recurrent laryngeal nerve paralysis.