Sarcoidal granulomas in the spleen associated with multiple carcinomas

Sarcoid reactions are relatively rare manifestations of epithelioid cell granulomas associated with malignancy; they are especially found in the lymph nodes draining malignant tumors, but rarely found in other organs. We present a case of a 60-year-old female with sarcoid reactions in the spleen identified during the consecutive diagnosis and management of ovarian, breast, and thyroid carcinomas during a period of about 2 years. The symptoms and laboratory data suggestive of systemic sarcoidosis were absent except for a slight mediastinal lymphadenopathy detected only by a computed tomographic scan. The splenic granulomas were accompanied by dendritic cells of mature and immature types, the latter being different from the reported nodal counterparts. To our knowledge, this is the first reported case of splenic sarcoid reactions associated with multiple cancers, and the first reported immunohistochemical detection of dendritic cells in splenic granuloma.

Phase II study of cladribine with rituximab (R-2-CdA) therapy in patients with relapsed indolent B-cell non-Hodgkin's lymphoma

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Background: Although cladribine has been reported to be one of active purine analogs against indolent B-cell non-Hodgkin's lymphoma (B-NHL), there are few reports of combination usage of cladribine and rituximab. We conducted a multicenter phase II study to investigate efficacy and toxicity of cladribine with rituximab (R-2-CdA) therapy for relapsed indolent B-NHL. Methods: Eligibility criteria were as follows: relapsed pts with indolent B-NHL from systemic chemotherapy, ages less than 75 years; PS 0–2 by ECOG's scale. Patients received 0.09mg/kg of cladribine intravenously (2 hrs infusion) on days 1 to 5 and 375mg/m2 of rituximab intravenously on days 1 and 15, every 4 weeks, for a total of 4 cycles. Primary endpoint was overall response rate (ORR). Secondary endpoints were % complete response (%CR), 2 years progression free survival (2-y PFS), and 2 years overall survival (2-y OS). Results: A total of 20 out of 45 planned patients were enrolled and received R-2-CdA therapy from Apr 2005 to Jul 2007. Their median age was 58.5 (42–72), and the median number of prior regimens was 2 (1–3). Histologies included 16 follicular lymphomas, 2 MALT lymphomas, 1 nodal marginal B cell lymphoma, and 1 lymphoplasmacytic lymphoma. Fifteen pts (75%) were previously treated with rituximab. The ORR was 90% with 70% of % CR. Median PFS was 20.1 months (5.6–32.9 months) at a median follow-up time of 27 months. 2-y PFS and 2-y OS were 63.2% (95%CI, 28.1–67.8%), and 89.5% (95%CI, 69.8–97.2%), respectively. Severe neutropenia and thrombocytopenia of grade 3 or 4 were observed in 15% and 10% respectively. Conclusions: R-2CdA therapy was demonstrated to have high activity with durable PFS and acceptable toxicity in relapsed indolent B-NHL, even if patients were previously treated with rituximab. Although a large-scaled further trial remains to be needed, R-2-CdA therapy could be a good option of salvage therapy in relapsed indolent B-NHL.

No significant financial relationships to disclose.

A forest bathing trip increases human natural killer activity and expression of anti-cancer proteins in female subjects

We previously reported that forest bathing trips enhanced human NK activity, number of NK cells, and intracellular anti-cancer proteins in lymphocytes, and that the increased NK activity lasted for more than 7 days after the trip in male subjects. In the present study, we investigated the effect of forest bathing trip on human NK activity in female subjects. Thirteen healthy nurses, age 25-43 years, professional career 4-18 years, were selected with informed consent. The subjects experienced a three-day/two-night trip to forest fields. On day 1, the subjects walked for two hours in the afternoon in a forest field; on day 2, they walked for two hours each in the morning and afternoon in two different forest fields; and on day 3, the subjects finished the trip and returned to Tokyo after drawing blood and completing a questionnaire. Blood and urine were sampled on the second and third days during the trip, and on days 7 and 30 after the trip. NK activity, numbers of NK and T cells, and granulysin, perforin, and granzymes A/B-expressing lymphocytes in the blood samples, the concentrations of estradiol and progesterone in serum, and the concentrations of adrenaline and noradrenaline in urine were measured. Similar control measurements were made before the trip on a normal working day. The concentrations of phytoncides in the forests were measured. The forest bathing trip significantly increased NK activity and the numbers of NK, perforin, granulysin, and granzymes A/B-expressing cells and significantly decreased the percentage of T cells, and the concentrations of adrenaline and noradrenaline in urine. The increased NK activity lasted for more than 7 days after the trip. Phytoncides, such as alpha-pinene and beta-pinene were detected in forest air. These findings indicate that a forest bathing trip also increased NK activity, number of NK cells, and levels of intracellular anti-cancer proteins in female subjects, and that this effect lasted at least 7 days after the trip. Phytoncides released from trees and decreased stress hormone levels may partially contribute to the increased NK activity.

Forest bathing enhances human natural killer activity and expression of anti-cancer proteins

In order to explore the effect of forest bathing on human immune function, we investigated natural killer (NK) activity; the number of NK cells, and perforin, granzymes and granulysin-expression in peripheral blood lymphocytes (PBL) during a visit to forest fields. Twelve healthy male subjects, age 37-55 years, were selected with informed consent from three large companies in Tokyo, Japan. The subjects experienced a three-day/two-night trip in three different forest fields. On the first day, subjects walked for two hours in the afternoon in a forest field; and on the second day, they walked for two hours in the morning and afternoon, respectively, in two different forest fields. Blood was sampled on the second and third days, and NK activity; proportions of NK, T cells, granulysin, perforin, and granzymes A/B-expressing cells in PBL were measured. Similar measurements were made before the trip on a normal working day as the control. Almost all of the subjects (11/12) showed higher NK activity after the trip (about 50 percent increased) compared with before. There are significant differences both before and after the trip and between days 1 and 2 in NK activity. The forest bathing trip also significantly increased the numbers of NK, perforin, granulysin, and granzymes A/B-expressing cells. Taken together, these findings indicate that a forest bathing trip can increase NK activity, and that this effect at least partially mediated by increasing the number of NK cells and by the induction of intracellular anti-cancer proteins.

Total body irradiation and granulocyte colony-stimulating factor-combined high-dose cytarabine as a conditioning regimen in allogeneic hematopoietic stem cell transplantation for advanced myelodysplastic syndrome: a single-institute experience

In this study, we retrospectively evaluated the efficacy and safety of total body irradiation (TBI) and granulocyte colony-stimulating factor (G-CSF)-combined high-dose cytarabine as a conditioning regimen for allogeneic hematopoietic stem cell transplantation (HSCT) in patients with advanced myelodysplastic syndrome (MDS). We evaluated 22 patients with advanced MDS, including refractory anemia with excess blasts (RAEB; n=10), RAEB in transformation (n=2), acute myelogenous leukemia transformed from MDS (n=6) and chronic myelomonocytic leukemia (n=4). The conditioning regimen consisted of 12 Gy of TBI and high-dose cytarabine (3 g/m(2)) every 12 h for 4 days, and the cytarabine was combined with continuous administration of G-CSF. The stem cell sources were bone marrow or peripheral blood stem cells from human leukocyte antigen (HLA)-identical siblings (n=12) and bone marrow from HLA serologically matched unrelated donors (n=10). Three patients experienced disease relapse, two of whom died of disease progression. Of 22 patients, 16 are currently alive and disease-free. The 5-year estimated overall survival, disease-free survival, relapse and non-relapse mortality rates are 76.7, 72.2, 16.6 and 14.1%, respectively. These results suggest that G-CSF-combined high-dose cytarabine could be a promising component of the conditioning regimen of allogeneic HSCT for advanced MDS, providing a low incidence of both relapse and treatment-related mortality.

Febrile ulceronecrotic Mucha-Habermann disease: a case report and a review of the literature

This report describes the case of a 76 year old man who suffered from febrile ulceronecrotic Mucha-Habermann disease (FUMHD). Despite this patient's typical clinical and histological findings, the fulminating course led to death. Polymerase chain reaction (PCR) analysis of the skin lesions showed that the infiltrating cells were monoclonal in origin and were from an aberrant clone. FUMHD is a very rare, febrile variant type of pityriasis lichenoides et varioliformis acuta, and is characterised by necrotic cutaneous ulcerations associated with high fever and systemic manifestations. Including this present case, only 18 cases of FUMHD have been reported. FUMHD can occur in both adults and children, although there are several differences between the manifestations of the disease in the two groups. One major difference is prognosis: all cases resulting in fatality are of the adult type, whereas no fatal cases have been reported among children. The aberrant clone detected by PCR may be responsible for host responses, resulting in the severe symptoms observed in this disorder.

Granulocyte transfusion as a treatment for enterococcal meningoencephalitis after allogeneic bone marrow transplantation from an unrelated donor

Bacterial meningoencephalitis occurring in the pre-engraftment period after bone marrow transplantation (BMT) is a rare complication, and the feasibility of granulocyte transfusion (GTX) in such cases remains to be elucidated. A 37-year-old man developed enterococcal meningoencephalitis during a severely granulocytopenic pre-engraftment period after BMT. Despite therapy with appropriate antibiotics, cultures of blood and cerebro-spinal fluid (CSF) continued to grow Enterococcus faecalis, and he developed rapid mental deterioration and seizure. Granulocytes were collected from his HLA-mismatched, ABO-matched sibling with subcutaneous injection of granulocyte colony-stimulating factor (G-CSF) and oral dexamethazone. Transfusion of 4.4 x 10(10) granulocytes resulted in a 12-h post-transfusion granulocyte increment of 2.0 x 10(9)/l, and maintained peripheral blood granulocyte counts above 0.5 x 10(9)/l for 3 days. A rapid increase of granulocytes in CSF was also observed, and cultures of blood and CSF became negative after GTX. A transient worsening of seizure was observed as a potential side effect of GTX. The patient subsequently developed septic shock because of Pseudomonas aeruginosa and died. Further studies are warranted to evaluate the clinical efficacy of GTX for the treatment of uncontrolled infections in granulocytopenic stem cell transplant recipients.

Dose-adjusted preemptive therapy for cytomegalovirus disease based on real-time polymerase chain reaction after allogeneic hematopoietic stem cell transplantation

We have prospectively evaluated the efficacy of real-time PCR-guided preemptive therapy for CMV diseases in allogeneic hematopoietic stem cell transplant recipients with grades II-IV acute GVHD. The dose of ganciclovir was adjusted according to the viral load determined by real-time polymerase chain reaction (PCR). On detecting CMV reactivation in the plasma, ganciclovir was initiated at a dose of 5 mg/kg body weight once daily, and the dose was increased to twice daily if viral load continued to increase after initiating ganciclovir. In 39 evaluable patients, CMV reactivation assessed by real-time PCR became positive in 30 (77%). One developed CMV gastroenteritis before PCR became positive. Thus the remaining 29 patients were treated preemptively with ganciclovir. The dose of ganciclovir was increased in 12 patients (41%) of preemptively treated patients for increasing viral load. CMV diseases were diagnosed in two patients (one gastroenteritis and one retinitis), and late CMV disease was diagnosed in one patient (gastritis). The treatment was generally well-tolerated, but three patients (10%) developed neutropenia (neutrophil count less than 1.0 x 10(9)/l). In conclusion, real-time PCR-guided preemptive therapy with decreased dose of ganciclovir is feasible and does not increase the frequency of CMV diseases if the dose is adjusted according to the viral load.

Tumour invasion and metastasis are promoted in mice deficient in tenascin-X

BACKGROUND

Tenascin-X (TNX) is a member of the tenascin family of large oligomeric glycoproteins of the extracellular matrix (ECM). To determine whether TNX plays a part in tumour invasion and metastasis and to disclose its normal physiological role, we disrupted its gene in mouse embryonic stem cells by homologous recombination and created mice deficient in TNX.

RESULTS

TNX-null mutant (TNX-/-) mice arose at normal frequency and showed no obvious defects during their adult life. However, when TNX-/- mice were subcutaneously inoculated in foot-pads with a highly invasive and metastatic cell line, B16-BL6 melanoma cells, the primary tumour size at 30 days after inoculation in the TNX-/- mice had increased by 1.2-fold compared with that in wild-type mice, and the invasion to the ankle and pulmonary metastasis in TNX-/- mice were also augmented by 2.2-fold and 6.8-fold, respectively, compared to those in wild-type mice. To disclose the molecular mechanism(s) of the promotion of tumour invasion and metastasis in TNX-/- mice, we measured the protein levels of matrix metalloproteinases (MMPs), which are recognized as playing a key role in these events, in the foot-pad homogenates of TNX-/- mice prior to the inoculation of melanoma cells. Gelatin zymography showed that the activities of proMMP-2, active MMP-2 and proMMP-9 were significantly higher in TNX-/- mice than in wild-type mice. Furthermore, a Northern blot analysis demonstrated that this increased activity of MMP-2 in TNX-/- mice was due to the induced expression of MMP-2 at the transcriptional level. The elevated expression of MMP-2 and MMP-9 resulted in decreased laminin levels, to less than half that of wild-type mice in the homogenates of TNX-/- mice.

CONCLUSIONS

TNX deficiency led to an increase in the production of MMPs, and the increased activity of MMPs may result in the degradation of laminin. Consequently, the melanoma cells inoculated in TNX-/- mice might facilitate invasion and metastasis. These results imply that TNX is required for impeding the invasion and metastasis of tumour cells.

Comparative analysis of host responses related to immunosuppression between measles patients and vaccine recipients with live attenuated measles vaccines

Measles virus infection induces a profound immunosuppression. We analyzed in a time-dependent manner peripheral bloods of one to two-year-old children immunized with live attenuated measles vaccines, compared with age-matched measles patients, for immunosuppression. In contrast to transient severe lymphopenia with measles patients, primarily due to extensive apoptosis of a broad spectrum of uninfected lymphocytes, neither apoptosis nor lymphopenia occurred with measles vaccine recipients. Increase in number and activation of NK cells, which might compensate for the lymphopenia in measles patients, were not found with the vaccinees. While cell surface expression of apoptosis-related molecules such as TNF-related apoptosis-inducing ligand (TRAIL), TRAIL-receptors, CD95(Fas) and Fas-ligand, and plasma interferon-gamma were increased for measles patients, they remained unchanged after vaccination. Plasma interleukin (IL)-18, which is responsible for inducing apoptosis in several infectious diseases, was increased predominantly with measles patients, whereas the increase remained marginal with the vaccinees. IL-10 was elevated transiently in both measles patients and vaccinees. Decrease in plasma IL-12, which is often correlated with T cell suppression, was not found for both cases. Serum IgM and IgG antibodies to measles virus were induced at lower titers in the vaccinees than measles patients. These results indicate that in contrast to wild-type measles virus, live measles vaccines hardly provoked host cytokine responses that lead to apoptotic cytolysis of uninfected lymphocytes, lymphopenia and immunosuppression, and thereby induced weaker immune responses to the virus.

Novel mutation in the PML/RARalpha chimeric gene exhibits dramatically decreased ligand-binding activity and confers acquired resistance to retinoic acid in acute promyelocytic leukemia

OBJECTIVE

All-trans retinoic acid (RA) resistance in acute promyelocytic leukemia (APL) has been a serious clinical problem in differentiation-inducing therapy. However, the mechanisms underlying acquired RA resistance in APL patients are not well understood.

MATERIALS AND METHODS

We recently established a spontaneous RA-resistant APL cell line (UF-1) from a patient and used this cell line as an excellent in vitro model for RA-resistant clinical situations. We investigated the structural and functional abnormalities of chimeric PML/RARalpha gene in UF-1 cells and preserved materials from the original patient.

RESULTS

A novel point mutation was detected in the ligand-binding (E) domain of the RARalpha portion of the PML/RARalpha gene in UF-1 cells. This mutation resulted in amino acid substitution of Arg611 (CGG) for Trp611 (TGG) in the short-form PML/RARalpha protein, which corresponded to Arg276 in wild-type RARalpha. Importantly, the same mutation was also detected in the preserved materials from the original patient. COS-1 cells were transiently transfected with cDNA encoding wild-type and mutant PML/RARalpha constructed by site-directed mutagenesis and performed RA-binding assay. Interestingly, RA-binding activity was dramatically decreased in the mutant PML/RARalpha compared with that of the wild-type chimeric protein, suggesting that this single amino acid substitution is critical for RA binding.

CONCLUSIONS

These results strongly suggest that a novel point mutation in the ligand-binding domain of the RARalpha portion (Arg611) of the chimeric PML/RARalpha gene decreased sensitivity to all-trans RA. We conclude that acquisition of the PML/RARalpha mutation is one possible mechanism for development of RA resistance in patients with APL in vivo.

Hypercalcemia after High-Dose Chemoradiotherapy for Refractory Multiple Myeloma; Subject Heading

A 43-year-old man with refractory myeloma underwent allogeneic bone marrow transplantation from his HLA-matched sibling. He was conditioned with TBI (12 Gy) followed by melphalan (140 mg/m(2) ). Immediately after conditioning was initiated, he began complaining of severe lumbago, and the level of serum calcium rose from 2.25 to 3.34 mmol / l. However, the biochemical markers for tumor-lysis syndrome such as potassium, uric acid, and lactic dehydrogenase remained unchanged. Hydration with saline and pamidronate were started, but he developed acute renal failure requiring hemodialysis for 3 weeks. His plasma parathyroid hormonerelated protein (PTHrP)-NH2-terminal (3.9 pmol/l) and serum PTHrP-C-terminal (125.0 pmol / l) levels markedly increased immediately after conditioning. These results suggested that the increased release of PTHrP from myeloma cells, which resulted from destruction of myeloma cells by conditioning, was the primary contributes to the occurrence of hypercalcemia. We should be aware of the occurrence of hypercalcemia when high-dose therapy is to be given to patients with refractory myeloma.

High-sensitivity analysis of cyanide by capillary electrophoresis with fluorescence detection

A capillary electrophoretic method for a high-sensitivity analysis of cyanide has been developed. Cyanide was derivatized with 2,3-naphthalenedialdehyde and taurine to give a fluorescent product of 1-cyanobenz[f]isoindole. This compound was detected with high sensitivity by fluorescence detection. The detection limit was 0.1 ng/mL, and the calibration curve was linear over the range 0.1-200 ng/mL. The precision of the migration time of within-run assays (n = 6) of 1 ng/mL cyanide standard solution was 0.14%. The precision of the peak area for the same runs was 1.0%. This method was applicable to blood analysis. Detection of the cyanide derivative by UV was also examined.

[Follicular lymphoma in two brothers]

Two brothers, whose parents had a history of exposure to atomic bomb radiation, developed non-Hodgkin's lymphoma. The younger brother, a 48-year-old man, was diagnosed as having follicular small-cleaved cell lymphoma in October, 1996. He had extranodal lymphoma involvement of the right kidney, bone marrow and skin, in addition to generalized lymphadenopathy. He was treated with intermittent COP chemotherapy, and good control of the lymphoma was obtained. The elder brother, aged 50 years, was diagnosed as having follicular mixed cell lymphoma in May, 1998. He also had extranodal lymphoma involvement of the right parotid gland and bone marrow, as well as generalized lymphadenopathy. After one course of CHOP chemotherapy, he developed paresis of the lower legs and was found to have a mass at the Th5-6 vertebrae by CT scan. After four courses of CHOP chemotherapy followed by ESHAP chemotherapy and radiotherapy, he achieved complete remission, and has since been well. Follicular lymphoma occurring among siblings is rare. Further cytogenetic and molecular studies may provide a better understanding of its etiology.

Presence of multiple HIV type 1 subtypes among mothers and children in Japan

We collected blood samples from 70 HIV-1-infected pregnant women and 76 babies born to HIV-1-infected women in Japan, from 1989 to 1999. To analyze the genetic diversity of HIV-1 among mothers and children, we sequenced the C2-V3 regions of HIV-1 gp120. Phylogenetic tree analysis of these regions revealed that multiple HIV-1 subtypes, A, B, D, E, and G, were circulating among mothers and children in Japan. Thus, the genetic heterogeneity of HIV-1 among mothers and children in Japan is steadily increasing, although the number of cases remains small. Perhaps the longest term survivor, an 11-year-old child with a vertical HIV-1 subtype G infection in Japan, is one of our subjects.

Clinical and bacteriological profiles of patients with typhoid fever treated during 1975-1998 in the Tokyo Metropolitan Komagome Hospital

Patients with typhoid fever presenting to the Tokyo Metropolitan Komagome Hospital during the period 1975-1998 were retrospectively investigated. All cases were diagnosed by a positive culture for Salmonella typhi in either of their clinical specimens. Of the total number of 130 patients, 57% contracted the disease abroad; this population increased in later years as the total numbers of cases decreased. The period from disease onset to diagnosis averaged 14 days with 20% of the cases requiring over three weeks to establish a diagnosis. As for symptomatology relative bradycardia was seen in less than half of the cases, and rose spots or splenomegaly in less than one third. A positive blood culture was the most frequent test establishing the diagnosis followed by a positive stool culture. Intestinal bleeding was recognized in as many as 35 cases (27%) and even intestinal perforation occurred in two cases (1.5%). Chloramphenicol was most commonly employed during the early study period, however, during the late period it was replaced by fluoroquinolones. The clinical cure rate was 98% with regimens that include fluoroquinolones/quinolone; however it was 87% with the other antimicrobial regimens. Bacteriological relapse occurred in 25% of the non-fluoroquinolone group while only in 2.0% in the fluoroquinolone/quinolone group. Four strains of Salmonella typhi that were multi-resistant to chloramphenicol, ampicillin and cotrimoxazole were isolated in travelers from Asia. Early diagnosis by appropriate bacteriological examination regardless of classical symptomatology should be stressed and the use of fluoroquinolones is warranted in the treatment of typhoid fever.

Identification of reaction products of methamphetamine and hydrogen peroxide in hair dye and decolorant treatments by high-performance liquid chromatography/mass spectrometry

The effect of hydrogen peroxide, a main component of hair dye and decolorant treatments, on methamphetamine (MA) was studied. Two analytical methods, thin-layer chromatography (TLC) and high-performance liquid chromatography/mass spectrometry (LC/MS), were used for the separation and identification of MA derivatives. Mixtures of MA solutions and hydrogen peroxide that had been incubated at 39 degrees C for 24 h were shown to contain para-hydroxy MA by TLC and para-, meta- and ortho-hydroxy MAs by LC/MS. In addition, MA N-oxide and N-hydroxy MA were found in MA/hydrogen peroxide mixtures immediately after mixing. Therefore, we concluded that MA changed to MA N-oxide and N-hydroxy MA before changing to para-, meta- and ortho-hydroxy MAs.

Herpes simplex mimicking herpes zoster in a child immunized with varicella vaccine

A 5-year-old boy had zosteriform vesicular lesions 4 years after immunization with varicella vaccine. PCR analyses of DNA extracted from the crusts revealed herpes simplex virus type 1 infection. Virologic examinations should be performed before the vesicular lesion is attributed to the varicella-zoster virus vaccine strain.

[Two cases of typhoid fever with reduced susceptibility to fluoroquinolones]

Two separate febrile Indian patients who reside in Japan and had recently returned from their country were diagnosed as suffering from typhoid fever. Fluoroquinolone therapy was clinically ineffective and the addition of a third-generation cephalosporin was required in each case. Each strain of Salmonella Typhi was resistant to nalidixic acid in vitro and also showed higher minimal inhibitory concentration to other quinolones than usual susceptible strains. Similar cases of typhoid fever responding poorly to quinolone treatment have been observed in the Indian subcontinent, south-east Asia and central Asia since the early 1990s, and potential spread by travelers into Japan is of serious concern. Although quinolones still remain the drugs of choice for treatment of typhoid fever, physicians should be aware of the possibility and implications of clinical treatment failure.

[Idiopathic hyperammonemia following allogeneic bone marrow transplantation for refractory lymphoma]

Idiopathic hyperammonemia (IHA) is a rare but serious complication of stem cell transplantation. We report a patient with immunoblastic lymphoadenopathy-like T-cell lymphoma who developed IHA 10 days after allogeneic bone marrow transplantation from an HLA-matched unrelated donor. Despite intensive supportive care, the patient died due to this metabolic disorder two days later. Being mindful of the possibility of IHA in patients who develop confusion and respiratory alkalosis soon after stem cell transplantation would allow earlier treatment and might improve the chance of survival.

Simultaneous chiral analysis of methamphetamine and related compounds by capillary electrophoresis

A capillary electrophoretic method for the simultaneous chiral analysis of nine cationic drugs (18 enantiomers) has been developed. These drugs are methamphetamine (MA), amphetamine, dimethylamphetamine, ephedrine (EP), norephedrine, methylephedrine, 3,4-methylenedioxymethamphetamine, 3,4-methylenedioxyamphetamine and 3,4-methylenedioxy-N-ethylamphetamine. The chiral selector, which was added to the electrolyte, was a mixture of beta-cyclodextrin and heptakis(2,6-di-O-methyl)-beta-cyclodextrin. The detection limits of all enantiomers were 0.1 microg/ml, and the intermediate precisions of migration time and peak area of within-run assays (n=6) were under 0.3% and 1.4%, respectively. The calibration curves of the peak area of (1R,2S)-(-)-EP and S-(+)-MA were linear in the range 0.2-500 microg/ml. This method was applicable to urine analysis.

Extensive lymphopenia due to apoptosis of uninfected lymphocytes in acute measles patients

Infection with measles virus induces a transient immunosuppression, which occasionally results in fatal opportunistic infections. To obtain fundamental information about the mechanism, we examined peripheral blood mononuclear cells (PBMC) from acute measles patients aged from infants to 35 years old, obtained at various times from incubation periods to 103 days after onset of rash, for the number of lymphocyte subsets by flowcytometry. The data were analyzed for relationships between aging of the patients and the severity of immunosuppression. In classical measles cases, infected lymphocytes detected as a minor population during the incubation period disappeared soon after onset of rash, whereas in the cases of serious illness, the infected cells persisted longer after the rash. At the onset of rash, remarkable lymphopenia had already occurred in all measles cases with reduction in cell numbers of CD4+ T cells, CD8+ T cells, B cells, neutrophils, and monocytes. In contrast, natural killer (NK) cells were increased in number and activated, which might be a response compensatory for the lymphopenia. Apoptosis-associated molecules such as CD95(Fas) and TNF-related apoptosis-inducing ligand-receptor (TRAIL-R) were highly expressed on the cell surface of most surviving non-infected lymphocytes, and DNA fragmentation was also observed upon incubation in vitro. These results suggested that the profound lymphopenia was primarily due to extended death of non-infected blood cells caused by apoptosis. The severity and duration of the lumphopenia were age-dependent; less severe in young children whereas much severer in infants under one year of age as well as adolescents and adults. From these results, it was suggested that remarkable lymphopenia due to apoptosis of uninfected cells is one of the principal causes for immunosuppression induced by measles virus infection, and is correlated with the age-dependent severity of the disease.

Primary structure, genomic organization and expression of the major secretory protein of murine epididymis, ME1

The mouse cDNA and its genomic clones encoding the epididymal secretory glycoprotein ME1 were identified. The Me1 gene spans 15kb with four exons and three introns. The deduced amino-acid sequence of the ME1 cDNA revealed that it consists of 149 amino acid residues, which contain a signal peptide characteristic of secretory proteins, six cysteine residues and a proline-rich region conserved in the orthologous proteins. Northern blot analysis revealed that 1.3kb ME1 mRNA is highly expressed in the mouse epididymis. The polyclonal antibodies generated against human HE1 (ME1 orthologous protein) expressed in bacteria reacted with approximately 17 to 25kDa components in mouse epididymis crude extract. The reduction of the molecular mass of the recombinant ME1 protein with the digestion of glycopeptidase A indicated that it is modified by Asn-linked glycosylation.

Herpes zoster in immunocompetent and immunocompromised Japanese children

BACKGROUND

To confirm epidemiological features of herpes zoster among children with or without immunosuppression, herpes zoster patients who had presented to this hospital were retrospectively investigated.

METHODS

Medical records were reviewed for the 92 cases of pediatric herpes zoster patients diagnosed during the period from 1981 to 1998. The age at onset of herpes zoster and of varicella, the interval between varicella and zoster, the dermatomal distribution of herpes zoster and complications were compared between immunocompetent and immunocompromised children.

RESULTS

The mean age at onset of zoster in immunocompetent children was 8.5 +/- 4.0 years and in immunosuppressed children was 9.7 +/- 3.8 years. The age at onset of varicella was significantly lower (1.6 +/- 1.8 years) in immunocompetent than in immunosuppressed children (4.6 +/- 2.7 years). The interval between varicella and zoster was 6.2 +/- 3.2 years in immunocompetent children. More than 80% of patients with acute leukemia or malignant lymphoma had herpes zoster within 2 years after diagnosis of malignancy. Lesions of herpes zoster were most frequently found in the thoracic nerve regions. Five of 11 zoster patients with cutaneous dissemination, three of five zoster patients having aseptic meningitis and three of four patients complicated facial palsy were children without underlying disease.

CONCLUSIONS

The present study confirmed that varicella in the first year of life was a risk factor in immunocompetent children, as reported previously. Herpes zoster in children without immunosuppression was found not to be as mild as generally accepted.

Rabies control in Japan

In 1957 Japan succeeded in eradicating rabies, which had been endemic since the 18th century, due to the registration and confinement of family dogs, the elimination of stray dogs, and the compulsory vaccination of dogs. At present, however, vaccination coverage of family dogs is far lower than the required level of 70%. The facilities that are presently able to investigate rabies are limited in number. In addition, few medical institutions keep rabies vaccine in stock or offer postexposure vaccination to travelers bitten by animals in rabies endemic areas. Moreover, rabies immunoglobulin (RIG) cannot be given to such individuals because RIG is not produced at present in Japan, nor is it authorized to be imported. To keep Japan free from any rabies deaths, an improvement in vaccination coverage among dogs and in the supply of postexposure prophylaxis is required, and the establishment of a rabies surveillance system is also considered to be essential.

The relationship between technical parameters of external beam radiation therapy and complications for localized prostate cancer

BACKGROUND

This study was performed to review retrospectively the clinical course of chronic rectal bleeding as a complication of external beam radiation therapy for localized prostate cancer and to analyze the relationship between technical parameters of radiation therapy and the complications.

METHODS

Seventy-one patients with stages A2, B and C were treated with local-field radiotherapy (total dose 52.5-66 Gy, daily dose 2.0-3.28 Gy, field area 30-81 cm2, number of fields 3-15 ports, planning simulations X-ray or CT-based) between 1989 and 1998 at three institutions. The protocols were consistent during this same period at these institutions.

RESULTS

Multivariate analysis revealed pretreatment PSA and Gleason sum to be statistically significant predictors of 5 year prostatic specific antigen (PSA) relapse-free rates in a median follow-up period of 42 months (range 12-119 months). The significant risk factors for higher grading of acute morbidity were a biological equivalent dose, alpha/beta = 10(BED10) > or =65 Gy, dose per fraction > or =3.0 Gy, field area > or =42 cm2, fewer ports and X-ray planning simulation. However, no parameter was associated with higher grading of late morbidity. Eleven patients (15.4%) experienced a late GI complication: grade 1 (4.2%), grade 2 (9.8%), grade 3 (1.4%). The median time to occurrence of rectal bleeding was 12 months after radiotherapy and the mean duration of morbidity was 11 months.

CONCLUSIONS

Higher total dose and dose per fraction, larger field area, fewer ports and X-ray simulation increased the grades of acute morbidity. A majority of chronic rectal bleedings were transient and responded to conservative treatment.

[A neonatal varicella case confirmed early to be infected with varicella-zoster virus using PCR analysis]

A neonatal varicella case confirmed early to be infected with varicella-zoster virus (VZV) using PCR analysis was reported. The mother developed an eruption on the following day the patient's birth and was diagnosed as varicella at 3 day of age. The neonate received immunoglobulin and acyclovir (17.5 mg x twice). She was speculated to develop varicella on the 5 to 10 day of age. Eruptions were noted, however, on the 13 day of age, although she was confirmed to be infected with VZV using PCR on the 6 day of age, and her symptoms were much milder than that foreseen. Delay of development and mildness of her symptoms may be attributed to immunoglobulin and acyclovir given on the 3 day of age. PCR method was very useful in determining early that she was infected with VZV.

High-performance liquid chromatography study on effects of permanent wave, dye and decolorant treatments on methamphetamine and amphetamine in hair

Black hairs that had been removed from a methamphetamine (MA) addict were treated with permanent wave, dye or decolorant liquids, and MA and amphetamine (AP) were quantified by a high-performance liquid chromatography/chemiluminescence detection method. The concentrations of MA and AP in the hair decreased significantly in all cases. Both MA and AP were stable in the permanent wave treatments, but not stable in the dye or decolorant treatments. As possible reasons for the decrease, the elution of MA and AP from hair in the permanent wave treatment, and the degradation of MA and AP in the dye or decolorant treatments might be considered. These results suggested that treatments of hair with permanent wave, dye or decolorant liquids interfered with determination of MA and AP in hair.

[Natural killer-like T-cell lymphoma appearing in the duodenum with recurrence in a variety of extranodal organs]

A 48-year-old man was admitted to Keio University Hospital in April 1995 with complaints of right abdominal pain and weight loss. Hypotonic duodenography showed a mass located in the 3rd portion of the duodenum. Endoscopic biopsy specimens disclosed diffuse large cell non-Hodgkin's lymphoma of the duodenum. The patient was initially treated with 2 courses of CHOP, albeit with no response. A pancreatoduodenectomy and radiotherapy yielded a complete remission. A year later, lymphoma recurred in the right mandible salivary gland, and a second complete remission was obtained after 6 courses of CHOP and radiation. However lymphomas also recurred in the intestine, and lungs, and the patient died of disease progression 38 months after diagnosis. Lymphoma cells were surface CD3 and CD56 positive. An examination of resected intestinal tissues disclosed lymphoma cells morphologically resemble large granular lymphocytes with rearranged TcR genes. These findings indicated the diagnosis of natural killer-like (NK-like) T-cell lymphoma. Compared with previously reported cases of NK-like T-cell lymphoma, this case was noteworthy for an unusual clinical course characterized by initial appearance in the duodenum, recurrence in a variety of extranodal organs, and the relatively long-term survival of the patient.

[A case received pre-exposure immunization against rabies by intradermal injection of rabies vaccine because of allergic reaction to the component of the vaccine]

A female, 25 years of age, came to our clinic to receive pre-exposure immunization against rabies. In another hospital she was tested to find out whether she was allergic to the components of rabies vaccine (PCEC) manufactured by the Chemo-Sero-Theraptic Research Institute (Kaketsuken) by cutaneous reaction using a 2,000-fold diluted PCEC. She showed a positive reaction. In our clinic she was again examined by skin test using 0.1 ml of 10-fold diluted PCEC. She showed wheal and flare reaction. Further we tested using 0.05 ml and 0.1 ml of non-diluted PCEC. Her skin reaction did not increase by several mm in diameter. So we decided to immunized her against rabies with intradermal injections of PCEC instead of subcutaneous injections that is indicated by the manufacturer. The second intradermal injections were done to right and left forearms a week later. Then the third shot was given 4 weeks after the second. At 2 weeks after the third injection her blood sample was taken to measure anti-rabies antibody titer by ELISA method with Platelia rabies kit (Diagnostic Pasteur, France). She had 6.7 U/ml of anti-rabies ELISA antibody that was much higher than the protective level (0.5 IU/ml) officially recognized by WHO. Therefore, it is concluded that she had produced sufficiently high level of anti-rabies antibody with intradermal injection of PCEC. It is reasonably recommended to investigate further if the intradermal injection of PCEC will be an effective method as a pre-exposure immunization against rabies.

Serum thrombopoietin and erythropoietin levels in patients with acute promyelocytic leukaemia during all-trans retinoic acid treatment

Endogenous serum thrombopoietin (TPO) and various cytokines including erythropoietin (EPO), interleukin (IL)-3, IL-6, IL-11, granulocyte-colony stimulating factor (G-CSF), granulocyte-macrophage-colony stimulating factor (GM-CSF) and stem cell factor (SCF) levels were measured in five patients with acute promyelocytic leukaemia (APL) during all-trans retinoic acid (RA) treatment. During differentiation-inducing therapy, platelet counts slowly increased and reached a peak between days 29 and 46 (median day 35). Serum TPO levels increased parallel to the increasing platelet counts and reached a maximum level during the first 10-20 d of all-trans RA treatment. The circulating TPO levels then decreased in inverse correlation to the platelet counts. These unique changes in serum TPO levels revealed that TPO levels were not regulated by platelet or megakaryocyte mass in patients with APL during differentiation-inducing therapy, and it would appear that TPO levels are directly regulated by all-trans RA during the first 10-20 d of treatment. In addition, the change in circulating EPO levels and reticulocyte counts were similar to that of the TPO levels and platelet counts during all-trans RA treatment, suggesting a close relationship between TPO and EPO signalling.

A homology modeling method of an icosahedral viral capsid: inclusion of surrounding protein structures

A methodological development is presented for homology modeling of an icosahedrally symmetric assembly of proteins. In the method, a main-chain structure of an asymmetric unit of a protein assembly is constructed and structure refinement is performed, taking the surrounding symmetry-related proteins into consideration with rotational symmetry boundary conditions. To test the procedure, three models of a poliovirus capsid were constructed with different modeling conditions based on the X-ray structure of a rhinovirus capsid. Model S and model N were constructed with and without considering surrounding proteins, respectively. Model N2 was obtained by refinement in rotational symmetry boundary conditions of the structure of model N. The three models were compared with the X-ray structure of a poliovirus capsid. Root mean square deviations and C alpha distances indicate that model S is the most accurate. Examination of the intermolecular short contacts indicates that model S and model N2 are superior to model N, because they do not make severe intermolecular short contacts. Symmetric intermolecular interactions are important for both the structural fragment search and energy minimization to predict better loop structures. The programs developed in this study are thus valuable in homology modeling of an icosahedral viral capsid.

Vertical infection of human immunodeficiency virus as an imported infectious disease

BACKGROUND AND METHODS

In Japan, 26 children who vertically acquired human immunodeficiency virus (HIV) infection had been reported as at February 1997. Little information was published about their epidemiological backgrounds and the rate of perinatal HIV transmission in Japan remains unknown. To learn the epidemiological features of perinatal HIV infection in Japan, we examined the medical records of five perinatally infected children.

RESULTS

Three of five mothers were Japanese and two others were South East Asian. Four of them acquired HIV infection abroad and one became infected through her spouse who had acquired infection abroad. Therefore, HIV infection in these five cases can be regarded as an imported infectious disease. None of the five mothers noticed their HIV infection before their pregnancy. One mother was found to be HIV seropositive during her pregnancy, but the others did not notice their HIV infection until their delivery.

CONCLUSIONS

To reduce the incidence of perinatally HIV-infected children it is necessary to lower the incidence of mother-to-infant HIV transmission. In Western countries they have succeeded in reducing the risk for perinatal HIV transmission with perinatal zidovudine therapy. To prescribe the preventive therapy against perinatal HIV transmission, it is essential to know if pregnant women are infected with HIV or not. Therefore, women of childbearing age should accept voluntary prenatal HIV testing. At the same time, they should be offered such programs that can enable them to receive timely counseling, besides medical treatment, if they are found to be HIV infected.

[Anti-rabies antibody levels observed in subjects who were bitten by supposed rabid animals abroad and received post-exposure immunization]

From December of 1990 to December of 1997, 119 subjects visited to our hospital to receive post-exposure therapy using purified chick embryo cell rabies vaccine manufactured by the Chem-Sero-Theraptic Institute (Katestuken), because they had been bitten by supposed rabid animals abroad. The forty of the subjects (male: 25, female: 15) wished to have their anti-rabies antibody levels examined. The number of samples taken after 5 or 6 shots rabies vaccine were 30 and 15, respectively. The antibody levels after 6 shots of rabies vaccine varied from 1.0 IU/ml to 10.1 IU/ml. After 5 shots the antibody levels fluctuated from under 0.1 IU/ml to over 8.8 IU/ml, and 3 subjects were found to have antibody titers of under 0.5 IU/ml which is the WHO minimal protective level. Two of these 3 subjects found to have antibodies of 1.0 IU/ml and 3.1 IU/ml. after the 6th injection. However, these 3 subjects had the hazard to have rabies despite post-exposure immunization, because the incubation period of rabies is found to be 1-3 months in about 60% of the cases. The potency of Kaketsuken's rabies vaccine should be increased to provide higher antibody levels.

Increased heating efficiency of hyperthermia using an ultrasound contrast agent: a phantom study

It is known that there are large temperature elevations in proximity to air bubbles during US (ultrasound) heating. The existence of tiny air bubbles in the target tissue may enhance the temperature elevation in US hyperthermia. To examine this hypothesis, phantom tissue experiments using an US contrast agent consisting of tiny air bubbles surrounded by a 5% (w/v) human albumin shell (Alb) were performed. As a phantom tissue, a 2 cm cube of beef was used. The phantom tissue was heated with or without the US contrast agent by an US hyperthermia device for 3 min. The heating device was operated at 1.5 MHz with the US intensity of 0.9 W/cm2. Physiological saline solution, iodized oil, and ethanol were used for control experiments. The effect of multiple needle punctures to the beef phantom was also examined. The temperature elevation rate (TER) was defined as the ratio of temperature elevation by heating with Alb or control materials to the temperature elevation by US heating alone. The TER of Alb was 1.7, whereas the TERs of the control materials and of the multiple needle punctures were approximately 1. The administration of Alb significantly increased the temperature in US hyperthermia. In addition, the heating efficiency of Alb was compared to the effect of an increase in the US intensity. Phantom tissue was heated at various US intensities. When the US intensity was increased from 0.9 to 1.8 W/cm2, the temperature elevated by approximately 1.7-fold. Thus, the effect of the administration of Alb was almost equivalent to the effect of increase in US power intensities from 0.9 to 1.8 W/cm2 in the present experimental settings. The results suggest that the US contrast agent can be a potential enhancer in US hyperthermia.

Simultaneous determination of cyanide and thiocyanate in blood by ion chromatography with fluorescence and ultraviolet detection

An ion chromatographic method for the simultaneous determination of cyanide and thiocyanate in blood has been developed. After extraction by adding water and methanol to blood, cyanide was derivatized with 2,3-naphthalenedialdehyde and taurine to give a fluorescent product of 1-cyanobenz[f]isoindole. This compound was detected with high sensitivity by fluorometry and the underivatized thiocyanate was detected by ultraviolet absorption. The detection limits were 3.8 pmol ml(-1) for cyanide and 86 pmol ml(-1) for thiocyanate, and the recoveries from blood were ca. 83% and ca. 100%, respectively. The proposed method was successfully applied to the analysis of both anions in blood from smokers, non-smokers and fire victims.

Restoration of retinoid sensitivity by MDR1 ribozymes in retinoic acid-resistant myeloid leukemic cells

Complete remission is achieved in a high proportion of patients with acute promyelocytic leukemia (APL) after all-trans retinoic acid (RA) treatment, but most patients relapse and develop RA-resistant APL. We have previously reported that both RA-resistant HL-60 (HL-60R) and APL cells express P-glycoprotein and MDR1 transcripts; and these cells differentiate to mature granulocytes after culture with RA and P-glycoprotein antagonist. Ribozymes have been shown to be able to intercept a target RNA by catalytic activity. To address the role of MDR1 in overcoming RA-resistance in APL cells, we investigated the biologic effects of ribozymes against the MDR1 transcript in HL-60R cells. These ribozymes efficiently cleaved MDR1 mRNA at a specific site in vitro. The 196 MDR1 ribozyme was cloned into an expression vector, and stably transfected (HL-60R/196Rz) cells were obtained. Expression of MDR1 transcripts was decreased in HL-60R/196Rz cells compared with parental HL-60R and empty vector-transfected (HL-60R/neo) cells. Interestingly, RA inhibited cellular proliferation and induced differentiation of HL-60R/196Rz cells in a dose-dependent manner, suggesting reversal of drug resistance in HL-60R cells by the MDR1 ribozyme. These data are direct evidence that P-glycoprotein/MDR1 is responsible in part for acquired resistance to RA in myeloid leukemic cells. The MDR1 ribozyme may be a useful tool for investigating the biology of retinoid resistance and may have therapeutic potential for patients with RA-resistant APL.

Point mutations in the S and pre-S2 genes observed in two hepatitis B virus carriers positive for antibody to hepatitis B surface antigen

Two hepatitis B virus (HBV) carriers who had antibodies to HBV surface antigen (anti-HBs) were studied. Case 1 was a 47 year old woman positive for hepatitis B e antigen (HBeAg), and case 2 was a 61 year old man positive for antibody to HBeAg (anti-HBe) and DNA-polymerase (DNA-p). Neither case had received the HBV vaccine. The nucleotide sequences of the HBV-DNA extracted from the patients' sera were determined within the pre-S2 and S genes. Seven out of nine S gene clones from case 1 and six out of nine S gene clones from case 2 had an amino acid replacement from Thr or Ile to Ser at codon 126 in the alpha-determinant of the S gene. Amino acid substitution of codon 145 of the S gene previously reported was not observed. Although two previous reports on HBV escape mutant carriers with both anti-HBs and HBeAg described some deletions in the pre-S2 gene, our cases did not show these deletions. Our analysis indicated that carriers with the HBV escape mutant did not always have pre-S2 gene deletions. We found two HBV escape mutant carriers who had amino acid substitutions at codon 126 in the S gene due to point mutation without any deletions in the pre-S2 gene.

High incidence of breakthrough varicella observed in healthy Japanese children immunized with live attenuated varicella vaccine (Oka strain)

In order to know the rate of occurrence of varicella among vaccinees (breakthrough varicella: BV), questionnaire postcards were sent to 593 healthy children who had received varicella vaccine (Oka strain) from March 1987 to December 1989. The questionnaire survey was repeated once a year until January 1996. The annual attack rate from the 1st to 3rd questionnaire was approximately 12%: however, from the 5th to 8th one it was 1-4%. To February 1996, the cumulative attack rate was 157/459 (34.2%). This rate was comparable to that among vaccinees who had confirmed seroconversion; namely, 51/132 (38.6%). These rates are much higher than those reported by other authors. All BV cases were clinically mild; even subjects who had received the vaccine 7 years prior to the disease showed mild symptoms. The high incidence may be partly explained by the regional epidemiology of varicella. The decrease in annual incidence with time after vaccination may be due to the following reasons: some vaccinees remained free from BV owing to reinforcement of their immunity from subclinical infection of varicella-zoster virus (VZV) and others from diminution of opportunity for exposure to VZV with increasing age. Varicella vaccine seems to be effective in modifying the symptoms of varicella, but not potent enough in protecting from VZV infection.

[Varicella in adulthood: clinical features, severity scores, source of infection and complications]

Varicella has been thought to be one of the representative infectious disease in childhood, but recently we are under the impression that adults contracting varicella are increasing in number. On the other hand, they say that varicella generally causes a serious illness in adult patients. So we investigated signs and symptoms of varicella, source of infection, occupations of adult patients, except those who were immunologically compromised, by means of medical records, to know the characteristics of varicella in adulthood. According to the varicella severity score proposed by Nagai et al., varicella in the hospitalized adult patient was found to be much severer than that in children. The most remarkable symptoms, were high fever and sore throat, and these were the main reason of hospitalization in most of our patients. Although severity scores were very high in admitted adult patients with varicella, their clinical courses were not serious, and most of them recovered with only supportive therapy. These patients rarely suffered from complications, like pneumonia. If adult patients with varicella hospitalized in the early stage and received supportive care, they could recover without any complications. In most cases of adult varicella the source of infection was unknown. In the case of married persons, however, many of them were infected through their child. When adults contract varicella, not only the patients themselves suffer from high fever and sore throat, but also they act as the source of infection, if they are medical care workers. Furthermore, in public, the contraction of varicella results a socioeconomic loss from suspension of business caused by the illness. Prophylaxis with varicella vaccine, therefore, should be considered, when there are people who have never contracted varicella, whether or not they are medical staff.

[Types of rabies vaccines which were locally injected to the subjects bitten by animals abroad]

In recent years there have been a number of subjects who were bitten by supposed rabid animals in foreign rabies-epizootic countries and visited our hospital to received post-exposure therapy after their return to Japan. WHO recommends immediate washing of the wound with soap and water, application of human anti-rabies immunoglobulin and administration of tissue-culture rabies vaccine at 0, 3, 7, 14, 30, and 90 days after exposure. However, tissue-culture vaccines, are expensive and they are not always used in all parts of the world. The author checked whether the victims of animal bite were injected with rabies vaccines abroad or not and investigated the type of rabies vaccine when they were vaccinated. About a half of the consulted victims were locally injected with rabies vaccine. By mean of certificates of inoculation or empty boxes of vaccine, types of rabies vaccines were proved in 40 subjects of which 38 received tissue-culture vaccines. Sample-type vaccine was administered to one subject and suckling mouse vaccine was done to another one. When post-exposure prophylaxis was continued after return to Japan, it is important to know the sort of rabies vaccine injected abroad, because brain-tissue vaccines are less effective in inducing antibody than tissue-culture vaccines. Consequently both physicians and travelers should keep in mind that even now brain-tissue vaccines are used in some areas of the world.

False identification of urinary ephedrine as methamphetamine by gas chromatography/mass spectrometry with a DB-17 column

A 17-year-old motorcyclist was killed in a traffic accident. The urine sample collected at autopsy was screened by the Toxi-Lab system; it showed a possible presence of either methamphetamine (MA) or ephedrine (Eph). Gas chromatography-mass spectrometry (GC-MS) was carried out for a trifluoroacetyl (TFA)-derivatized sample after extraction with an Extrelut column. A peak was detected at the same retention time as that of the authentic Eph by GC-MS with a DB-17 wide-bore column; the mass spectrum of the peak was, however, very similar to that of MA. The presence of Eph and absence of MA were proved by GC-MS using a DB-1 column. The Eph in the urine was further confirmed by high performance liquid chromatography (HPLC)-MS using an ODS column. By the REMEDi HS system, Eph and methylephedrine were determined in the urine, and their concentrations (hydrochloride salt) were 0.752 and 2.13 micrograms/ml, respectively. Ethanol was detected as well in the blood (1.55 mg/ml) and urine (2.01 mg/ml) by a pulse heating method. Nicotine, caffeine and dihydrocodeine were also qualitatively detected in the urine by Toxi-Lab, HPLC-MS and REMEDi HS systems. The present case warned that urinary Eph can be misidentified as MA by GC-MS with an intermediately polar column after TFA derivatization.