Chronic spontaneous epidural hematoma in the lumbar spine with cauda equina syndrome and severe vertebral scalloping mimicking a spinal tumor: a case report

BACKGROUND

Chronic spinal epidural hematomas (SEHs) are rare clinical entities. SEH with vertebral scalloping is extremely rare, with only a few cases having been reported to date. We report a unique case of spontaneous chronic SEH in the lumbar spine with severe vertebral scalloping mimicking an epidural tumor.

CASE PRESENTATION

A 71-year-old man presented with a 2-month history of lumbar pain and a 3-week history of paresthesia and pain in the right lower extremity, hypesthesia in the perineal and perianal regions, and bladder dysfunction. Computed tomography following myelography revealed an epidural mass lesion on the right side that compressed the dural sac and was associated with severe bony scalloping on the posterior wall of the L4 vertebral body. Magnetic resonance imaging (MRI) on T1- and T2-weighted images revealed a space-occupying lesion with heterogeneous intensity, and T1-gadolinium images showed an intralesional heterogeneous enhancement effect. A tumoral lesion in the spinal canal was suspected, based on preoperative imaging; therefore, a total spinal tumor resection was planned. Intraoperative findings revealed that the brownish lesion adhered to the dura and epidural tissues in the spinal canal, and the space-occupying mass in the scalloped cavity of the posterior wall of the L4 vertebra was encapsulated in red-brownish soft tissues. The lesion was totally resected in a piecemeal fashion, and pathological examination revealed a mixture of tissues that contained a relatively new hematoma with hemoglobin, as well as an obsolete hematoma with hemosiderin and amyloid deposits. The mass was diagnosed as a chronic epidural hematoma with recurrent hemorrhage. The postoperative course was uneventful, and the preoperative neurological symptoms immediately improved.

CONCLUSIONS

The preoperative diagnosis of chronic SEHs is challenging, as MRI results may not be conclusive, particularly in patients with scalloping of bony structures. Thus, chronic SEHs should be considered as a differential diagnosis in cases of suspected tumoral lesions in the spinal canal. To the best of our knowledge, this is the first reported case of acute exacerbation of chronic SEH with cauda equina syndrome and severe vertebral scalloping.

A case of juvenile eosinophilic cholangitis: Rapid peripheral blood hypereosinophilia after admission leading to diagnosis

A 15-year-old boy was referred to our hospital with elevated hepatobiliary enzyme levels and jaundice. Magnetic resonance cholangiopancreatography performed at the previous medical facility revealed a stricture of the intrahepatic and extrahepatic bile duct. Computed tomography showed dilatation and wall thickness of the intrahepatic bile ducts. Primary sclerosing cholangitis or cholangiocarcinoma was suspected. Endoscopic retrograde cholangiopancreatography (ERCP) showed stricture in the intrahepatic and extrahepatic bile duct. On admission, the eosinophil count in the peripheral blood was normal; however, rapid hypereosinophilia in the peripheral blood was observed after admission, leading us to suspect eosinophilic cholangitis (EC). A bile duct biopsy showed inflammatory cells and eosinophil infiltration during a second ERCP. The patient was diagnosed with EC based on histopathology.

Population pharmacokinetics of tacrolimus in adult recipients receiving living-donor liver transplantation

OBJECTIVE

To characterize the pharmacokinetics of tacrolimus in adult recipients receiving living-donor liver transplantation (LDLT).

METHODS

Thirty-five patients were given tacrolimus as 18- to 60-h intravenous infusions after surgery, followed by a 4-week course of oral dose therapy (at 0900 hours and 2100 hours). Blood samples were collected daily in the morning (0800 hours) beginning the day after surgery. Whole blood concentration data were evaluated by nonlinear mixed-effect modeling using the program NONMEM and were characterized using a one-compartment model.

RESULTS

The clearance (CL, l h(-1)) was related to the grafted hepatic weight, postoperative days (POD), and hepatic and renal dysfunction. Interindividual variabilities in CL, volume of distribution (V), and bioavailability (F) were 57.4%. 39.7%, and 63.0%, respectively, and the correlation between individual CL and F was 0.776. Residual intraindividual variability was 2.9 ng ml(-1). Based on the estimated final parameters, a typical recipient of LDLT with grafted hepatic weight of 600 g and normal hepatic and renal function would have a CL of 0.737 l h(-1) on POD 0 and 1.14 l h(-1) on POD 30, V of 1.52 l kg(-1) and F of 6.8%.

CONCLUSIONS

Nonlinear mixed-effect modeling was useful for analysis of pharmacokinetic characteristics of tacrolimus in LDLT patients. Immediately after surgery, patients receiving LDLT showed a smaller CL value than other transplant patients, and CL value increased with POD within 30 days after surgery. The estimated population pharmacokinetic parameters can be applied for a priori dosage calculations in adult patients with LDLT.

Role of apoptosis in cisplatin-induced toxicity in the renal epithelial cell line LLC-PK1. Implication of the functions of apical membranes

The role of apoptosis and the implications of the functions of apical membranes in cisplatin-induced nephrotoxicity were investigated using the kidney epithelial cell line LLC-PK1. When LLC-PK1 cells were treated with 30 microM cisplatin, the number of floating cells was increased markedly. However, the number was not increased by treatment with 1 mM cisplatin, suggesting that different mechanisms were involved in the toxicities of these two treatments. DNA fragmentation, condensation of nuclear chromatin, and the absence of trypan blue staining suggested that cellular toxicity following treatment with 30 microM cisplatin for 24 hr was mediated predominantly by apoptosis. Specific activities of apical enzymes (gamma-glutamyltransferase, EC 2.3.2.2; and alkaline phosphatase, EC 3.1.3.1) in LLC-PK1 cells were decreased markedly by treatment with 30 microM cisplatin for 24 hr, whereas neither lactate dehydrogenase (LDH; EC 1.1.1.27) release nor a decrease in cellular protein content was observed following the same treatment. In addition, concomitant treatment with reduced glutathione completely attenuated both the apoptosis and the decrease of apical enzyme activities induced by 30 microM cisplatin. Neither DNA fragmentation nor condensation of chromatin was induced by treatment with 1 mM cisplatin for 12 hr. However, LDH release and a decrease in cellular protein level were induced by 1 mM cisplatin, suggesting that the toxic effect was due to necrosis. Under these conditions, specific activities of apical enzymes were not decreased. These results suggested that apoptosis was more responsible than necrosis for the loss of apical functions in cisplatin-induced toxicity in LLC-PK1 cells.

Synthesis and oral activity of pivaloyloxymethyl 7-[(Z)-2-(2-aminothiazol-4-yl)-2-methoxyiminoacetamido]-3(Z)- (4-methylthiazol-5-yl)vinyl-3-cephem-4-carboxylate (ME1207) and its related compound

7-[2-(2-Aminothiazol-4-yl)-2(Z)-methoxyiminoacetamido]-3(Z)- (4-methylthiazol-5-yl)vinyl-3-cephem-4-carboxylic acid (11, ME1206) and its 3-trans isomer (13) were prepared to test antibacterial activity. These compounds exhibited excellent antibacterial activity against both gram-positive and gram-negative bacteria, including beta-lactamase producing strains. The pivaloyloxymethyl esters (12 and 14) of the compounds (11 and 13) were prepared by esterification with pivaloyloxymethyl iodide. Among them, pivaloyloxymethyl 7-[(Z)-2-(2-aminothiazol-4-yl)-2-methoxyiminoacetamido]- 3(Z)-(4-methylthiazol-5-yl)vinyl-3-cephem-4-carboxylate (12, ME1207) showed good urinary recovery after oral administration in mice.

Sodium and pH dependent carrier-mediated transport of antibiotic, fosfomycin, in the rat intestinal brush-border membrane

The mechanism of intestinal absorption of an antimicrobial agent, fosfomycin (FOM), was investigated in rats using small intestinal brush-border membrane vesicles (BBMV). The uptake of [3H]FOM by BBMV was osmolarity- and temperature-sensitive and showed apparently saturable uptake kinetics consistent with the Michaelis-Menten equation, having Kt = 15.3 mM and Jmax = 7.78 nmol/30 s/mg protein at 37 degrees C. An overshoot uptake of FOM was observed in the presence of an inwardly direct Na+ gradient. The replacement of extravesicular Na+ with choline or mannitol significantly reduced the uptake. An addition of a protonophore, FCCP, significantly decreased the initial uptake of FOM in the absence of Na+ gradient but in the presence of a H+ gradient (pHin = 7.5, pHout = 6.0), whereas in the absence of a H+ gradient no significant difference was observed between the uptakes at an acidic pH (pHin = pHout = 6.0) and a neutral pH (pHin = pHout = 7.5). An inside negative potassium diffusion potential induced by valinomycin enhanced significantly the uptake of FOM. The uptake of FOM in the presence of both Na(+)- and H(+)-gradients was significantly inhibited by phosphate, arsenate and phosphonoformic acid (PFA), which are specific inhibitors of phosphate transport, but not by D-glucose. Based on these results, it is concluded that FOM transport in the small intestine is partially shared with the Na(+)-phosphate cotransport system and in part occurs via a H(+)-gradient dependent carrier-mediated system.

Biological activities of new anthracyclines containing fluorine, FAD104 and its metabolites

From various new anthracyclines containing fluorine in their sugar moieties, 7-O-(2,6-dideoxy-2-fluoro-alpha-L-talopyranosyl)adriamycinone-14-hemi pimerate (FAD104) has been selected for clinical investigation, because of its excellent antitumor activity and solubility. In this paper, the mechanism whereby FAD104 exhibits good antitumor activity in vivo was studied through experiments in vitro in comparison with doxorubicin (DOX). FAD104 had weaker activity than DOX in DNA single and double strand scission in P388 cells and in binding to calf thymus DNA. FAD104 was taken up by P388 cells faster than DOX. The ester linkage in FAD104 was gradually hydrolyzed at neutral pH. FAD104 was metabolized to 7-O-(2,6-dideoxy-2-fluoro-alpha-L-talopyranosyl)adriamycinone (FT-ADM) when incubated with mouse or human serum. In mouse serum the esterase activity was about 100 times higher than in human serum. The product of nonenzymatic and enzymatic esterolysis, FT-ADM, was rapidly taken up by P388 cells and accumulated, reaching at a 9.7-fold higher level than DOX. Thus FAD104 was less active than DOX in itself, but it showed much higher activity through conversion into FT-ADM, due to the action of esterase or to spontaneous and gradual hydrolysis at physiological pH. 7-O-(2,6-Dideoxy-2-fluoro-alpha-L-talopyranosyl)adriamycinol (FT-ADM-OH), another metabolite found in mouse serum had the least biological activity among the fluorine-containing anthracycline glycosides, but its activity was still higher than DOX.

[Synthetic cephalosporins. V. Synthesis and antibacterial activity of 3-alkylthio-7 beta-[(Z)-2-(2-aminothiazol-4-yl)-2-(O-substituted oxyimino)acetamido]cephalosporins and related compounds]

3-Alkylthio-7 beta-[(Z)-2-(2-aminothiazol-4-yl)-2-(O-substituted oxyimino)acetamido]cephalosporins (6 and 7) and the 3-methoxy analogues (10) were prepared by coupling diphenylmethyl 7-amino-3-alkylthio-3-cephem-4-carboxylate (1 and 2) or diphenylmethyl 7-amino-3-methoxy-3-cephem-4-carboxylate with (Z)-2-(2-tritylaminothiazol-4-yl)-2-(O-substituted oxyimino)acetic acid (4), followed by deprotection and subjected to examination of antibacterial activities. The pivaloyloxymethyl esters (8 and 9) of the compounds (6 and 7) were also prepared and oral activities of these esters were compared with those of the parent compounds (6 and 7). The cephalosporins (6a-j and 7a-c) had potent and wide antibacterial spectra against Gram positive and Gram negative bacteria which were comparable to those of cefixime or cefteram. Among them, the cephalosporins (6f and 7c) and the pivaloyloxymethyl esters (8b and 9b) had good in vivo efficacy in mice against infections of Escherichia coli No. 29 and especially 8b showed high urinary recovery in mice.

Synthetic cephalosporins. II. The synthesis and oral activity of 7-[R-2-amino-2-(3-chloro-4-hydroxyphenyl)acetamido]-3-methylthio-3- cephem-4-carboxylic acid and related compounds

A series of 3-methylthio-3-cephem-4-carboxylic acids were prepared to test their antibacterial activities, and 7-[R-2-amino-2-(3-chloro-4-hydroxyphenyl)acetamido]-3-methylthio-3-ce phe m-4- carboxylic acid was found to be a new orally active antibiotic.

In vivo actions of bestatin-related compounds in relation to their actions in vitro

A study was performed to elucidate the effects of low-molecular-weight enzyme inhibitors on enzyme networks in vivo. Seven compounds, including bestatin and its 5 derivatives and arphamenine B, were tested, with each of them being administered to mice at the dose of 200 micrograms/day for 8 consecutive days. The spectrum of enzymatic changes thus induced were extensive and were not simply explainable by the in vitro actions of each agent administered. Nevertheless, a multivariate study on the changes in enzyme networks showed some degree of interrelationship between the in vitro and in vivo actions of the agents under study. The present findings seem to certify that the direct enzyme-inhibiting effect motivates the extensive movement of enzyme networks in vivo, although the latter often seems rather paradoxical at a glance.

Relationship between enhancement of morphine analgesia and inhibition of enkephalinase by 2S, 3R 3-amino-2-hydroxy-4-phenylbutanoic acid derivatives

The effects of nineteen AHPA* derivatives were examined on morphine analgesia by tail-flick test in rats and on enkephalinase inhibition which was based on the formation of tyrosyl-glycyl-glycine from met-enkephalin. The correlation between the enhancement of morphine analgesia in vivo and enkephalinase inhibition in vitro was analyzed. The different analogs varied considerably in the degree of enhancement of morphine analgesia and inhibition of enkephalinase. A close relationship between enkephalinase inhibition expressed by IC50 in vitro and enhancement of morphine analgesia in vivo was observed in thirteen out of nineteen AHPA derivatives examined. One of other six AHPA derivatives which showed weak effectiveness in potentiating on morphine analgesia but was highly potent as an enkephalinase inhibitor, caused potent analgesic action when it was applied intracisternally indicating poor penetration of the blood brain barrier. The possibility was discussed that some of other compounds excluded from the linear relationship might act on other enkephalin degrading enzymes such as aminopeptidase.