[Systemic neurolymphomatosis complicated in diffuse large B-cell lymphoma]

A 73-year-old woman was diagnosed with diffuse large B-cell lymphoma of the uterus (Stage IVB). After 3 courses of CHOP therapy, right abducens nerve paralysis appeared and was diagnosed as central nervous system infiltration with lymphoma cells. Although partial remission was obtained by chemotherapy with methotrexate, numbness and muscle weakness of all four limbs appeared asymmetrically and progressed subacutely. Nerve conduction velocity examination revealed mononeuritis multiplex, but we could not reach a final diagnosis. Steroid pulse therapy, chemotherapy including high-dose methotrexate, and radiation therapy were ineffective. On autopsy, histological examination of the peripheral nerves revealed systemic neurolymphomatosis.

Regulator of complement activation (RCA) locus in chicken: identification of chicken RCA gene cluster and functional RCA proteins

A 150-kb DNA fragment, which contains the gene of the chicken complement regulatory protein CREM (formerly named Cremp), was isolated from a microchromosome by screening bacterial artificial chromosome library. Within 100 kb of the cloned region, three complete genes encoding short consensus repeats (SCRs, motifs with tandemly arranged 60 aa) were identified by exon-trap method and 3'- or 5'-RACE. A chicken orthologue of the human gene 6-phosphofructo-2-kinase/fructose-2,6-biphosphatase 2, which exists in close proximity to the regulator of complement activation genes in humans and mice, was located near this chicken SCR gene cluster. Moreover, additional genes encoding SCR proteins appeared to be present in this region. Three distinct transcripts were detected in RNA samples from a variety of chicken organs and cell lines. Two novel genes named complement regulatory secretory protein of chicken (CRES) and complement regulatory GPI-anchored protein of chicken (CREG) besides CREM were identified by cloning corresponding cDNA. Based on the predicted primary structures and properties of the expressed molecules, CRES is a secretory protein, whereas CREG is a GPI-anchored membrane protein. CREG and CREM were protected host cells from chicken complement-mediated cytolysis. Likewise, a membrane-bound form of CRES, which was artificially generated, also protected host cells from chicken complement. Taken together, the chicken possesses an regulator of complement activation locus similar to those of the mammals, and the gene products function as complement regulators.

Prediction of functional outcome after stroke rehabilitation

OBJECTIVE

The purpose of this study is to identify predictors of functional outcome after acute stroke inpatient rehabilitation using raw Functional Independence Measure (FIM) total scores.

DESIGN

Multivariate analysis was performed on data collected retrospectively from stroke rehabilitation patients. Six independent variables were obtained from patients' medical records.

RESULTS

The FIM total scores at the time of discharge from the hospital correlated strongly with FIM total scores at the time of admission to the hospital and correlated negatively with age and OAI using the Spearman's rank correlation method. The FIM total scores at the time of hospital admission were the best predictor of FIM total scores at the time of discharge from the hospital. However, the nature of the stroke, gender, and LOHS did not correlate with FIM total scores at the time of discharge from the hospital.

CONCLUSIONS

Because FIM total scores at the time of hospital admission and discharge are highly correlated, FIM total scores at the time of hospital admission can be used to establish a rehabilitation program, to inform the patient and family about the possibility of recovery, and to assess the amount and quality of care given in the home or discharge placement.

[Swallowing rehabilitation using balloon catheter treatment evaluated by videofluorography in an elderly patient with Wallenberg's syndrome]

A 65-year old man was admitted with severe dysphagia, ataxia and aspiration pneumonia. Dysphagia and ataxia were caused by lateral medullary infarction (Wallenberg's syndrome). The swallowing abnormality was assessed by videofluorography and we attempted the balloon dilatation method for cricopharyngeal dysphagia. Three months after initiation of swallowing training, videofluorography (VF) showed that the magnitude of aspiration to the trachea had decreased and the patient began taking food by mouth. The balloon dilatation method is successful for chronic stage cricopharyngeal dysphagia and the VF test is useful for quantitative assessment of dysphagia and for deciding when to start oral intake in elderly patients.

[Activities of antimicrobial agents against 5,180 clinical isolates obtained from 26 medical institutions during 1998 in Japan. Levofloxacin--Surveillance Group]

The surveillance study was conducted to determine the antimicrobial activity of fluoroquinolones (ofloxacin, levofloxacin, ciprofloxacin, tosufloxacin) and other 20 antimicrobial agents against 5,180 clinical isolates obtained from 26 medical institutions during 1998 in Japan. The resistance to fluoroquinolones was remarkable in Enterococci, methicillin-resistant staphylococci and Pseudomonas aeruginosa from UTI. However, many of the common pathogens such as Streptococcus pneumoniae including penicillin-resistant isolates, methicillin-susceptible Stahylococcus aureus, Moraxella catarrhalis, the family of Enterobacteriaceae, Haemophilus influenzae including ampicillin-resistant isolates have been kept to be susceptible to fluoroquinolones. About 90% of P. aeruginosa isolates from RTI were susceptible to fluoroquinolones. In conclusion, the results from this surveillance study suggest that fluoroquinolones are useful in the treatment of various bacterial infections including respiratory infections.

Fasting insulin and leptin serum levels are associated with systolic blood pressure independent of percentage body fat and body mass index

OBJECTIVE

To examine the relationship between leptin and insulin serum levels and systolic and diastolic blood pressure in young men.

SETTING

Kobe University of Mercantile Marine, Kobe, Japan.

PARTICIPANTS

One hundred and ninety-eight male students aged 18-20 years (comprising 100% of those eligible).

DESIGN AND MEASUREMENTS

A cross-sectional survey of a sample of male college students was performed, with measurements to include anthropometry, blood pressure and blood tests after overnight fasting.

RESULTS

Compared with 90 men with an optimal blood pressure, 56 men with high-normal and high blood pressure had an increase in body mass index (23.7 +/- 5.2 versus 20.4 +/- 2.2 kg/m2), percentage body fat (21.7 +/- 8.0 versus 16.3 +/- 4.2%) and serum leptin (3.7 +/- 4.7 versus 1.5 +/- 0.8 ng/ml). In addition, they had greater serum insulin (59 +/- 31 versus 43 +/- 12 pmol/l) despite there being no differences in plasma glucose, resulting in a reduction of the ratio of glucose to insulin (x 10(6)) (107 +/- 43 versus 126 +/-, which is an estimate of insulin sensitivity in a nondiabetic population. Furthermore, the 56 men had higher serum triglyceride levels, although there was no difference in low density lipoprotein-cholesterol and high density lipoprotein-cholesterol between men with optimal and high-normal plus high blood pressure. Similar differences were found between men in a top versus low tertile of systolic and diastolic blood pressure. In multiple regression analysis, both log leptin and log insulin emerged as determinants for systolic blood pressure independent of body mass index and percentage body fat, but an association with diastolic blood pressure was only shown for log leptin.

CONCLUSION

Hyperleptinemia and hyperinsulinemia may be regulators of arterial pressure, independent of body mass index or percentage body fat.

Use of PCR serum in diagnosing and monitoring cytomegalovirus reactivation in bone marrow transplant recipients

We previously reported that the use of polymerase chain reaction (PCR) in detecting cytomegalovirus (CMV) DNA in serum (sPCR) enables the detection of CMV viremia, which has not been possible with other methods. In this study, the clinical usefulness of sPCR was investigated by comparison with the results of three other diagnostic methods, i.e., antigenemia assay (AG), shell vial culture test (shell vial), and complement-fixing (CF) antibody titer. The present study included 26 patients with hematological diseases who had undergone allogeneic bone marrow transplantation (BMT). A total of 347 samples were collected, and the results of the sPCR and AG methods were in agreement in 91.1% of the samples. When a subject was positive in both the sPCR and AG tests, and the other two tests (shell vial and CF) were also positive, CMV reactivation was surmised as definite. When only the result of the shell vial test or the CF test was positive, these results were taken as false-positives. The time at which the samples became positive in each of these four tests was 7.5 weeks post-BMT for sPCR, 7.0 weeks post-BMT for the AG test, 7.4 weeks post-BMT for the shell vial test, and 9.7 weeks post-BMT for the CF test. Thus, it was found that samples became positive at almost the same time for the sPCR, AG, and shell vial tests. Interstitial pneumonitis (IP) due to CMV developed in 3 subjects. These cases were positive in the sPCR, AG, and shell vial tests prior to the manifestation of symptoms of IP. The CF test did not become positive until after the onset of the disease. As the IP due to CMV was controlled with treatment, the sPCR and AG tests became negative. With the shell vial and CF tests, on the other hand, the test results continued to be positive even after the IP was cured. These findings demonstrate that the sPCR test method--like the AG test--yields few false-positive results. Therefore, the sPCR method is useful in early diagnosis of reactivation of CMV and for evaluation of the efficacy of therapy administered for IP. In addition, sPCR can be performed simultaneously on a large number of samples, and the evaluation of the test results is simple. We conclude that the sPCR test may be superior to the three other diagnostic methods for evaluation of serum samples from multiple institutions.

Comparison of venoarterial versus venovenous access in the cerebral circulation of newborns undergoing extracorporeal membrane oxygenation

This study was designed to compare venoarterial (VA) with venovenous (VV) access in the cerebral circulation of newborn infants during extracorporeal membrane oxygenation (ECMO). Among 14 infants with VA ECMO, 7 had no intracranial complications (group 1), while the others (group 2) developed intracranial hemorrhage (ICH). In contrast, among 19 infants with VV ECMO, only 1 developed ICH. Serial echocardiograms were performed before and after 1, 6, 12, and 24 h and 2 and 3 days of ECMO. The mean cerebral blood flow (CBF) velocities were measured in the anterior cerebral artery (ACA), right and left internal carotid arteries (Rt, Lt-ICA), basilar artery (BA), and right and left middle cerebral arteries (Rt, Lt-MCA). Ejection fraction (EF), cardiac output (CO), and stroke volume (SV) were also measured using standard echography. The velocity levels in the ACA, Rt-MCA, and Lt-MCA in VA ECMO were lower than those in VV ECMO, while those in the Lt-ICA and BA in VA ECMO were higher than those in VV ECMO. The EF, CO, and SV were lower in cases of VA ECMO than in VV ECMO. In cases of VA ECMO, there were no differences between groups 1 and 2 in velocities in the ACA, Rt-ICA, or Lt-ICA. However the velocities in group 2 in the BA, Rt-MCA, and Lt-MCA were lower than those in group 1 before and during ECMO. Similarly, the EF, CO, and SV were lower in group 2 (12.0%-31.0%, 0. 10-0.32 l/min, and 0.66-1.55 ml, respectively) than in group 1 (29. 5%-49.3%, 0.25-0.63 l/min, and 2.15-3.85 ml) during ECMO. However, in the infants on VV ECMO the CBF was either maintained or gradually increased before and during ECMO. Their cardiac parameters were: EF 46.1%-53.0%, CO 0.43-0.52 l/min, and SV 2.72-3.84 ml during ECMO. It is concluded that in VA ECMO CBF velocities, particularly in infants who developed ICH, decreased after the onset of ECMO in association with poor cardiac function, while in VV ECMO they were stable, probably due to normal systemic hemodynamics and cardiac function.

Cimetidine reduces impairment of cellular immunity after cardiac operations with cardiopulmonary bypass

OBJECTIVE

Depressive effects of cardiopulmonary bypass on cell-mediated immune responses may lead to postoperative infectious complications. We previously reported that cimetidine reduced postbypass depression of the cytotoxic activity of natural killer cells. This study evaluated cimetidine as an agent to preserve cellular immunity after cardiac operations.

METHODS

In a prospective randomized study, 20 patients were divided into two groups of equal size. Cimetidine-group patients received 400 mg of cimetidine intravenously before bypass and a 33 mg/hr intravenous infusion of cimetidine after the operation, continuing until the fifth postoperative day. Control-group patients received conventional perioperative therapy. Lymphocyte subsets, natural killer cell activity, percentage of CD56+CD16+ (percentage of natural killer cells), and percentage of CD11b+CD8+ (percentage of suppressor T lymphocytes) were measured perioperatively.

RESULTS

Although temporary postoperative reductions in percentages of CD3+, CD4+, and CD56+CD16+ cells were observed in both groups, CD8+ percentages on postoperative day 1 and CD11b+CD8+ percentages on postoperative days 1 and 3 in the cimetidine group were significantly lower compared with those in the control group (p = 0.01,p = 0.004, andp = 0.02, respectively). Temporary postoperative reduction of natural killer cell activity was also observed in both groups, but the natural killer cell activity on postoperative day 1 in the cimetidine group (17.1%) was significantly higher (p = 0.02) than that in the control group (8.20%).

CONCLUSIONS

Cimetidine counteracts depressive effects of cardiopulmonary bypass on cell-mediated immunity and may possibly reduce postoperative susceptibility to infection.

Thoracotomy for a patient with Stevens-Johnson syndrome: report of a case

Stevens-Johnson syndrome (SJS) is an uncommon eruptive disorder of the skin and mucous membranes with systemic manifestation. It is extremely unusual for patients with a past history of SJS to present with indications for surgery necessitating thoracotomy. We describe herein the perioperative management of a patient with SJS who underwent surgery for a spontaneous pneumothorax.

[A case of primary HIV-1 infection]

A previously healthy 28 year old Japanese man came to us with a genital ulcer which appeared 13 days before admission to our hospital. He had subsequently fever (40 degrees C), arthralgia, a sore throat and oral aphtha 6 days before admission. He had a history of sexual contact with a female commercial sex worker one week before his illness. On the day of admission, he had shallow ulcers on the lip, tongue and penis. Initial laboratory test included leukopenia and thrombocytopenia. His fever abated 3 days after admission. His condition and bicytopenia recovered completely after 12 days of admission. Although, his serum HIV-1 antibody was negative when he was admitted, 3 months later the antibody was seroconverted. And p24 antigen and HIV-1 RNA of stocked serum were positive. Diagnosis of primary HIV-1 infection was made. Recently, HIV-1 infection has been increasing in Japan. Consideration of this disease in differential diagnosis of acute febrile illness is necessary.

Isolation and structural characterization of pituitary adenylate cyclase activating polypeptide (PACAP)-like peptide from the brain of a teleost, stargazer, Uranoscopus japonicus

Pituitary adenylate cyclase-activating polypeptide (PACAP) is a novel neuropeptide consisting of 38-residue (PACAP 1-38) and a truncated form with 27 residues (PACAP 1-27) that plays several roles in tetrapods. We isolated a highly purified PACAP-like peptide from the brain of a teleost, the stargazer, by extracting of acetone-dried powder with acetic acid followed by high-performance liquid chromatography (HPLC) on gel-filtration, cation-exchange, and reverse-phase columns. Purification was monitored by sodium dodecyl sulfate-polyacrylamide gel electrophoresis (SDS-PAGE) and Western blotting analysis using an anti-PACAP 1-27 antiserum. The PACAP-like peptide thus obtained had a molecular mass of 4,623, determined by mass spectrometry, and its amino acid sequence showed 89 and 87% identity with those of ovine and frog PACAPs, respectively. These results indicate that a PACAP-like peptide, which is a highly homologous with tetrapod PACAP, is present in the teleost brain.

[A case of rapidly grown pulmonary blastoma]

A 78-year-old woman who had been in a local hospital with a complaint of cough and chest pain was referred to our hospital because a mass 12 cm in size was found in her right lung by a chest X-ray and CT. Within 3 weeks, the tumor rapidly developed to 19 cm in size. Malignant schwannoma of the lung was suspected by a percutaneus lung biopsy and the right upper and middle lobectomy was performed. Histological analysis of the tumor showed a biphasic structure with epithelial and mesenchymal component which was diagnosed pulmonary blastoma. Pulmonary blastoma is very rare, but it may be of benefit for the thoracic surgeon to establish methods of diagnosis and treatment of this disease.

Cardiorespiratory function as assessed by exercise testing in patients with non-insulin-dependent diabetes mellitus

Exercise testing was used to examine 19 cardiorespiratory diabetes mellitus patients, aged 32-68 years (body mass index, 27.8 +/- 4.8 kg/m2), and 16 healthy volunteers, aged 23-57 years (body mass index, 22.7 +/- kg/m2). A graded cycling exercise test was done, monitoring gas exchange, ventilation and heart rate. Values were significantly higher in the non-insulin-dependent diabetes mellitus (NIDDM) patients than in the controls for fasting blood glucose (P < 0.01), glycosylated haemoglobin (P < 0.01), body weight (P < 0.05) and body mass index (P < 0.05). The exercise testing produced values that were significantly lower in the patients with NIDDM than in the controls for percentage oxygen uptake (P < 0.05), maximum load (P < 0.05), maximum metabolic equivalent (P < 0.01) and maximum oxygen uptake per unit body weight (P < 0.01). Ventilatory capacity and forced expiratory volume at 1 sec did not differ significantly in the two groups. These results suggest that general fitness is diminished due to reduced cardiorespiratory function in patients with NIDDM.

[Clinical implications of mismatched uptakes of beta-methyl fatty acid analogue and thallium in infarcted myocardium: correlations with coronary stenosis and regional wall motion abnormality]

Myocardial perfusion and fatty acid metabolism were assessed by using myocardial single-photon emission computed tomography with thallium and beta-methyl-p-iodophenyl-pentadecanoic acid (BMIPP) during acute and/or late stages of myocardial infarction in 157 infarcted segments of 100 patients. The incidence of reduced thallium perfusion relative to BMIPP uptake ("T-type" mismatch) was significantly (p < 0.05) lower (9%) compared to that of reduced BMIPP uptake relative to thallium perfusion ("B-type" mismatch) (59%) or non-mismatched segment (32%). In an anteroseptal region, B-type dissociation had a significantly higher incidence compared to no or T-type mismatch; 68% vs. 27% vs. 5%, respectively, whereas the incidence of T-type uptake was relatively high in inferior and posterolateral regions; 13%, 11%, respectively. Severe coronary stenosis was observed in 76% of B-type segments and 72% of non-mismatched segments but in only 43% of T-type segments. The incidence of regional wall motion abnormality was significantly lower (46%) in the T-type mismatch segments when compared to the B-type (91%) or non-mismatched segments (96%). In conclusion, myocardial fatty acid metabolism was more markedly impaired compared to an involved coronary perfusion, resulting in the mismatch of perfusion and fatty acid metabolism. Coronary stenosis and regional wall motion abnormality are more closely related to "B-type" mismatch but not necessarily to "T-type" dissociation, probably because of attenuation artifacts in inferior and posterolateral regions in thallium scan.

Rupture of an isolated internal iliac artery aneurysm into the rectum: report of a case

Aneurysmal rupture into the intestinal tract is a rare but disastrous complication of an internal iliac artery aneurysm. We report herein the successful surgical repair of a fistula between a huge aneurysm of the right internal iliac artery and the rectum in an 81-year-old man. After a femoro-femoral cross-over bypass had been performed, the aneurysm was opened and its patent arterial branches were ligated with sutures. The fistula was then intra-aneurysmally sutured and covered with an omental flap. The diagnostic and therapeutic approaches to this severe complication are discussed with a review of the literature following the presentation of this case.

Response of glutamic acid decarboxylase to glucose but not arginine in islets

This study examined responses of glutamic acid decarboxylase (GAD65) and gamma-aminobutyric acid (GABA) to glucose in pancreatic islets. Islets isolated from Wistar rats were cultured for the three days under different concentrations of glucose (5.6, 11.1 or 16.7 mM) or arginine (2 x 10(-1)-2 x 10(-4) mM) for different periods of time. The expression of GAD65 increased 3.8- and 4.5-fold with the elevation of glucose concentrations as well as the prolongation of culture periods of time, while it did not increase with arginine. GABA content of islets did not change in a range of 5.6 to 16.7 mM glucose. These results suggest that normalization of hyperglycemia would reduce the expression of the autoantigen in islets, which might prevent islets from further destruction. To the contrary, the persistent hyperglycemia could interfere with insulin synthesis not by change of GABA in islets but by the destruction of islets through GAD65 expression.

A convulsant, 3-mercaptopropionic acid, decreases the level of GABA and GAD in rat pancreatic islets and brain

To investigate the properties of the gamma-aminobutyric acid (GABA) synthesizing enzyme, glutamate decarboxylase (GAD), in the brain and the pancreatic islets of the rat, GABA concentration in the brain and the pancreatic islets was measured after intraperitoneal administration of 3-mercaptopropionic acid (3-MP) at 25 mg/kg. 60 min after the administration of 3-MP, GABA concentration in the hypothalamus, the superior colliculus and the hippocampus of the brain decreased by 20-30% and in the pancreatic islets by 35%. The concentration in the pancreatic acini did not change. Western blotting showed that GAD activity in the pancreatic islets decreased after administration of 3-MP compared to the control. The activity of GAD in the pancreatic islets as well as brain can be modified by a convulsant, in this case 3-MP. These results suggest the properties of GAD may be similar in the pancreatic islets and brain.

Cardiorespiratory effects of weight reduction by exercise in middle-aged women with obesity

The cardiorespiratory responses to weight reduction due to physical exercise were examined in fourteen women with obesity, aged 36 to 67 years (Body Mass Index, 32.4 +/- 1.5 kg/m2). The patients were instructed to exercise at approximately 60% of maximum oxygen uptake for 2 h every day for approximately 3 months. To evaluate physical strength, a graded cycling exercise test was performed both before and after the exercise period, monitoring gas exchange, ventilation, and heart rate. After the exercise period the body mass index and percentage fat both decreased by 11% and 18%, respectively (P < 0.001), although lean body mass did not change; maximum oxygen uptake and maximum heart rate did not change significantly, but peak ventilation equivalent, maximum metabolic equivalent and maximum load increased by 12%, 14% and 11%, respectively (P < 0.05, P < 0.001 and P < 0.001, respectively). Maximum oxygen uptake per unit body weight increased by 5% (P < 0.001). These results suggest that weight reduction as a result of exercise improves cardiorespiratory function in middle-aged women with obesity.

[A case report of left ventricular-right atrial communication with tricuspid regurgitation due to infective endocarditis]

A case of 58-year-old man with a left ventricular-right atrial communication with tricuspid regurgitation due to infective endocarditis was reported. Surgical treatment was performed following intensive chemotherapy. The communication was found in the center of a vegetation on the septal leaflet. Closure of the communication and replacement of the tricuspid valve were done successfully. His postoperative course was uneventful.

A convulsant, 3-mercaptopropionic acid, decreases the level of GABA in pancreatic islets of rat as well as that of brain

To investigate the properties of the gamma-aminobutyric acid (GABA) synthesizing enzyme, glutamate decarboxylase (GAD), in the brain and the pancreatic islets of the rat, GABA concentration in the brain and the pancreatic islets was measured after administration of 3-mercaptopropionic acid (3-MP) at 25 mg/kg intraperitoneally. Sixty minutes after the administration of 3-MP, GABA concentration in the hypothalamus, the superior colliculus and the hippocampus of the brain decreased by 20-30% and in the pancreatic islets by 35%. The activities of GAD in the pancreatic islets and brain can be modified by a convulsant, in this case 3-MP. These results suggest the properties of GAD may be similar in the pancreatic islets and brain.

Leiomyosarcoma of the inferior vena cava causing Budd-Chiari syndrome--a case report

A forty-eight-year-old Japanese woman with leiomyosarcoma of the inferior vena cava presenting as Budd-Chiari syndrome is reported. A large tumor originating from the venous wall grew into the lumen, obstructing the hepatic vein, and extended up to the right atrium. Although this is a very rare tumor, care should be taken in order to make an early diagnosis and manage the condition effectively.

Contact allergies to topical corticosteroids

The patient, a 34-year-old Japanese woman who noticed worsening of her rash after using topical corticosteroid preparations on her neck, was patch tested for both commercial preparations and corticosteroids themselves. The patch test results revealed that she had a contact allergy to gold, oxytetracycline, and 2 types of corticosteroid (acetonides and esters) in 7 compounds (betamethasone valerate and dipropionate, hydrocortisone butyrate and hydrocortisone butyrate propionate, amcinonide, budesonide, and fluocinonide).

Possible role of preS2 peptides presented by MHC class I antigen in the pathogenesis of chronic hepatitis B

Many variations exist in the first 39 nucleotides of the preS2 (pre-S2; 1-39) region of the HBV genome. Based on the similarities of their coding amino acid sequences to those of prototype HBV, they were classified into 3 different types, adr-preS2, adw-preS2 and ayw-preS2. To clarify the meaning of these variabilities in the preS2 region, we studied the HLA class I phenotype of chronic hepatitis B patients having high levels of serum ALT. Our results indicated that in 12 of 14 chronic hepatitis patients infected with HBV type adr-preS2 had HLA-A24 phenotype whereas all of 7 patients infected with either adw- or ayw-preS2 HBV had HLA-A2 phenotype. This strong association between HLA class I phenotype and certain preS2 types of HBV infection was found only in patients with high serum ALT levels but not in patients with almost normal levels of serum ALT. Our results therefore suggest that in the generation of chronic hepatitis B a suitable combination between a fragment of preS2 antigen and HLA class I antigens of the infected host, such as adr-preS2 with HLA-A24 and either adw- or ayw-preS2 with HLA-A2, might be required.

[Left ventricular aneurysm with normal coronary arteriogram after myocardial infarction]

Left ventricular aneurysms after myocardial infarction are generally considered one of the complications of severe coronary artery disease. Postinfarction ventricular aneurysms with normal coronary arteriogram are rare. Only a few cases have been reported previously in Japan. We examined the incidence and the clinical characteristics of postinfarction ventricular aneurysms without coronary obstruction. Among the consecutive 1800 patients studied in our laboratory with selective coronary cineangiography and left ventriography, we found 5 (4 male, 1 female) patients with left ventricular aneurysms with no or minimal coronary arterial obstruction. The patient's ages ranged from 34 to 83 with a mean of 59. Interestingly, no patient had prior anginal history, and every case occurred with a first sudden attack of chest pain. The likely mechanisms causing the development of myocardial infarction were coronary spasm and/or thromboembolic accident. One patient, in whom a coronary induction test was performed, showed positive findings. It is possible that poor collateral circulation and well preserved contraction of viable myocardium in these patients bring about the formation of left ventricular aneurysm after myocardial infarction with normal coronary arteriogram.

[Microcystic adnexal carcinoma--a light and electron microscopic studies]

Microcystic adnexal carcinoma (MAC) in a 48-year-old Japanese male was studied. A firm nodule had appeared on the right side of his upper lip at the age of 38 years and then had gradually enlarged. Light microscopic examinations revealed numerous strands and islands of basaloid cells and keratinous cysts with desmoplastic stroma in the dermis and subcutaneous tissue. Some keratinous cysts showed early calcification and some contained pilar structures. Clear cells resembling sebaceous gland cells were observed in the strands of tumor cells connecting the keratinous cysts. In the middle dermis, there were small ductal structures containing amorphous eosinophilic material. Immunoperoxidase staining for carcinoembryonic antigen was focally positive in the lumina of small ducts, on the ductal lining surface of tumor cells, and in the contents of keratinous cysts. Electron microscopic examinations revealed tumor cells resembling non-keratotic keratinocytes, and containing tonofilaments, mitochondria, and vacuoles. In some parts, tumors were differentiated to various types of sebaceous gland, sweat duct, or sweat secretary segments. Sebaceous gland cells contained lipid droplets and glycogen. Tumors differentiated to sweat duct had a marked similarity to embryo eccrine duct in the lower epidermis because of the presence of multivesicular dense bodies and periluminal filamentous zones and the absence of myoepithelial cells. Tumors differentiated to sweat secretary segments had a similarity to embryo eccrine secretary segments because of the absence of multivesicular dense bodies, periluminal filamentous zones and myoepithelial cells.