Mediastinal pancreatic pseudocyst diagnosed based on black pleural effusion

Mediastinal pancreatic pseudocysts are rare complications of pancreatitis associated with alcohol consumption. Here, we report a case of mediastinal pancreatic pseudocyst. A 61-year-old Japanese woman presented to our hospital with epigastric pain and dyspnea. A chest radiograph revealed right-sided massive pleural effusion. Thoracentesis retrieved black pleural fluid with remarkably high fluid amylase levels were. Thoracic computed tomography (CT) after drainage revealed encapsulated fluid. Magnetic resonance cholangiopancreatography (MRCP) and endoscopic retrograde cholangiopancreatography (ERCP) were performed because abdominal CT and ultrasonography did not reveal any pancreatic problems. MRCP showed cystic masses and pancreatic tail cysts extending to the stomach and lower oesophagus. ERCP confirmed leakage of contrast medium from the pancreatic tail into the retroperitoneum. We diagnosed the patient with a pancreatic pseudocyst extending to the mediastinum. A mediastinal pancreatic pseudocyst should be considered a differential diagnosis in patients with black pleural fluid with a high amylase level.

Vogesella urethralis-induced aspiration pneumonia and bacteremia in an elderly man: a first case report and literature review

BACKGROUND

Vogesella species are common aquatic Gram-negative rods that were first reported in 1997. Vogesella urethralis bacterium was first isolated from human urine in 2020. Only two cases of disease caused by Vogesella species have been reported with no case of Vogesella urethralis-caused disease being reported as yet. Herein, we report a case of aspiration pneumonia and bacteremia caused by Vogesella urethralis.

CASE PRESENTATION

An 82-year-old male patient was admitted with dyspnea, increased sputum production, and hypoxia. Gram-negative rods were isolated from the blood and sputum cultures of the patient. He was diagnosed with aspiration pneumonia and bacteremia. Initially, Vogesella urethralis was wrongly identified as Comamonas testosteroni based on fully automated susceptibility testing; however, additional 16S rRNA gene sequencing identified the causative as Vogesella urethralis. The patient was treated with piperacillin and tazobactam. Unfortunately, he developed aspiration pneumonia again and died during hospitalization.

CONCLUSIONS

Since no database exists for rare bacteria in traditional clinical microbiology laboratories, 16S rRNA gene sequence analysis is useful. We report the first case of Vogesella urethralis-induced aspiration pneumonia and bacteremia.

Immunotactoid Glomerulopathy with Nontuberculous Mycobacterial Infection: A Novel Association

A 70-year-old woman underwent a renal biopsy due to nephrotic syndrome. She had suffered from nontuberculous mycobacterial infection (NTM) for 14 years. The patient was diagnosed as having membranoproliferative glomerulonephritis (MPGN) type 3 and immunoglobulin (Ig)-associated MPGN based upon LM/erythromycin and IF findings, respectively. In high-magnification imaging, electron-dense deposits showed immunotactoid glomerulopathy (ITG). There was no evidence of hematological cancer, and the patient improved after receiving treatments for NTM. To the best of our knowledge, this patient is the first to show an association between ITG and NTM. Although ITG is generally considered as related to lymphoproliferative disease, it is suggested that ITG is driven by bacterial infection and is a potential outcome of Ig-associated MPGN.

Sarcoidosis with marked necrosis in enlarged lymph nodes mimics mycobacterial infection: a case report

Background

Sarcoidosis is pathologically characterized by the formation of non-necrotizing epithelioid cell granulomas. However, pathological findings of patients with sarcoidosis have rarely revealed necrosis. We report here on a patient with sarcoidosis which needed to be distinguished from infectious disease because of marked necrosis in the lymph nodes.

Case presentation

A 46-year-old Japanese woman was referred to our hospital due to a dry cough and appetite loss. A chest X-ray and computed tomography revealed markedly enlarged mediastinal and hilar lymph nodes and hepatosplenomegaly. Surgical biopsy of these lymph nodes was performed in order to make a diagnosis. Pathological findings revealed epithelioid cell granuloma with marked necrosis that suggested infectious etiology such as mycobacterial and fungal infections. In addition to the pathological findings, immunoglobulin A (IgA) antibody for Mycobacterium avium complex (MAC), enlargement of lymph nodes and hepatosplenomegaly indicated disseminated MAC, while sarcoidosis was considered as another important differential diagnosis according to elevated angiotensin-converting enzyme, soluble interleukin-2 receptor and uveitis. While waiting for the results of the cultures of acid-fast bacilli, the symptoms of cough and consumption had worsened, and initiation of therapy was required before the confirmed diagnosis. The therapy for MAC was initiated because it was feared that immunosuppressive therapy containing corticosteroid for sarcoidosis could worsen the patient’s condition if MAC infection was the main etiology. However, the treatment for MAC was not effective, and it was clarified that no acid-fast bacilli were cultured in the liquid culture medium, so the diagnosis was corrected to sarcoidosis after reconsideration of clinical and pathological findings. Prednisolone (30 mg/day) was administered orally, and the patient’s symptoms and radiological findings improved.

Conclusion

Sarcoidosis must be considered even if pathological findings reveal marked necrosis, because rare cases of sarcoidosis exhibit extensive necrosis in lymph nodes. It is extremely important to carefully examine the clinical and pathological findings through discussion with the examining pathologist to reach the correct diagnosis.

Cholestatic Liver Injury Induced by Pembrolizumab in a Patient with Lung Adenocarcinoma

The anti-programmed cell death-1 protein monoclonal antibody, pembrolizumab is an immune checkpoint inhibitor. While it improves the prognoses of patients with advanced non-small-cell lung cancer, it has been reported to induce various kinds of immune-related adverse events, including hepatotoxicity. Despite the frequency of hepatotoxicity, there is only limited information available regarding the pathophysiology and treatment. We herein report a 48-year-old man with lung adenocarcinoma who was treated with pembrolizumab and developed cholestatic liver injury. In this case, the importance of evaluating the histology of hepatotoxicity and the effectiveness of ursodeoxycholic acid for cholestatic liver injury is indicated.

The diagnostic yield using ultrasound-guided needle-aspiration for subpleural primary lung cancer is not affected by the radiological properties of the lesions resulting from computed tomography

BACKGROUND

It is well known that ultrasound-guided needle-aspiration (USGNA) for intrapulmonary subpleural lesion in contact with the pleura is useful and safe, and its diagnostic yield is high. However, reports concerned with the analyses of cases with intrapulmonary subpleural lesion which could not be diagnosed using USGNA are limited. The objective of this study is to clarify the radiological properties of subpleural primary lung cancer which obstruct diagnosis by USGNA.

METHODS

The consecutive cases with subpleural primary lung cancer whose radiological properties could be confirmed by thoracic computed tomography (CT) without contrast enhancement (CE), and examined by USGNA at our hospital between January 1999 and December 2014 have been analyzed. All cases were given pathological diagnoses of primary lung cancer. The diagnostic yield by USGNA was calculated, and the properties of the lesions of the subjects were analyzed by means of thoracic CT without CE images and pathological findings.

RESULTS

87 consecutive cases (41-86 year olds, 75 males, 12 females) were analyzed. The overall diagnostic yield by USGNA was 86.2%. There was no statistically significant difference regarding the diagnostic yield concerning radiological properties such as cavities, small airspaces and low density areas in the lesions and their sizes. However, the diagnostic yield for the cases with squamous cell carcinoma was statistically significantly low (p=0.02).

CONCLUSION

Although the diagnostic yield of USGNA is not distorted by the radiological properties of lesions, it is statistically significantly low in cases with squamous cell carcinoma.

Small-cell lung cancer exhibiting spontaneous regression

A 56-year-old woman was admitted to our hospital because a chest X-ray and thoracic computed tomography (CT) scan revealed a heterogeneous tumor in the middle mediastinum during a visit to a nearby clinic for a consultation regarding a persistent cough and body weight loss. However, the tumor spontaneously decreased on thoracic CT performed on admission. Subsequently, a biopsy of the tumor using video-assisted thoracoscopy was performed. The pathological findings disclosed the tumor to be small-cell lung cancer with infiltration of CD8-positive T-cells exhibiting spontaneous regression. Cell-mediated immunity, including CD8-positive T-cells, may have relevance to the spontaneous regression of malignant tumors.

An autopsy case of subacute cor pulmonale due to pulmonary tumor cell emboli in a patient with gastric cancer

A 53-year-old woman was admitted to our hospital due to a severe respiratory condition and malnutrition. Radiological and electrophysiological findings suggested the existence of inexplicable cor pulmonale. Although we commenced to determine the causes of her severe condition, she suddenly died 3 days after admission. Postmortem autopsy revealed tumor cell microemboli in the small pulmonary arteries due to gastric cancer. Such a case of cor pulmonale as the first clinical manifestation is exceptionally rare. Occult malignancy should be considered as a differential diagnosis when one encounters a patient with subacutely aggravated respiratory condition and inexplicable cor pulmonale.

[A case of exogenous lipoid pneumonia with marked elevation of serum KL-6 and interstitial lung shadows due to aspiration of liquid paraffin]

A 64-year-old man who ingested liquid paraffin as a laxative for over two years, was admitted to our hospital with a persistent interstitial lung shadow and marked elevation of serum KL-6. He had no overt symptoms although his chest radiograph revealed ground glass opacities in the left lower lung field and right middle and lower lung fields. We performed fiberoptic bronchoscopy. Exogenous lipoid pneumonia was diagnosed based on microscopic analysis of the bronchoalveolar lavage fluid that revealed the presence of lipid-laden alveolar macrophages. We instructed the patient to discontinue liquid paraffin ingestion and observed his clinical course. The chest radiograph and thoracic computed tomography revealed a tendency to improve and serum KL-6 decreased with time. Serum KL-6 may be an important index of the severity of exogenous lipoid pneumonia.

[Case of Heerfordt's syndrome with prolonged peripheral nerve involvement]

A 28-year-old man complaining of myiodesopsia was given a diagnosis of uveitis. Subsequently he complained facial nerve palsy and enlargement of parotid gland. Heerfordt's syndrome was diagnosed based on the results of several examinations. Facial nerve palsy, enlargement of the parotid gland and uveitis were improved by systemic corticosteroid therapy. At present he is receiving systemic corticosteroid therapy, but numbness in the mouth, thought to be the involvement of the trigeminal nerve, remains. Systemic corticosteroid therapy is usually effective for most cases with Heerford's syndrome. On the other hand, there are some cases with the prolonged peripheral nerve involvement despite systemic corticosteroid therapy, as seen in this case. If peripheral nerve involvement is prolonged, it is necessary to consider small-fibre neuropathy as one possible cause.

[Clinical evaluation of meningeal carcinomatosis associated with primary lung cancer]

We evaluated diagnosis and treatment of four cases of meningeal carcinomatosis associated with primary lung cancer: case 1; small cell carcinoma (64 years old), case 2; small cell carcinoma (50 years old), case 3; adenocarcinoma (53 years old), and case 4; adenocarcinoma (55 years old). Determination of tumor markers in cerebrospinal fluid (CSF) together with the MRI findings that Gd-DTPA-enhanced T1-weighted image showing high intensity signal along the spinal cord was clinically useful in the diagnosis of meningeal carcinomatosis. Two of four patients received intrathecal chemotherapy and/or CSF drainage through Ommaya-Reservoir, resulting in dramatic improvement of various symptoms such as motor weakness and vesicorectal disorder. Intrathecal chemotherapy and placement of an Ommaya-Reservoir for CSF drainage should be considered to provide better Quality of Life (QOL) when patient can tolerate it.

Grafting neural stem cells improved the impaired spatial recognition in ischemic rats

To determine the possible therapeutic potential of neural stem cells (NSCs) introduced into the damaged central nervous system, we grafted adult hippocampus-derived NSCs into the hippocampus of rats with transient global ischemia. Transient four-vessel occlusion yielded 90-95% losses of pyramidal neurons in the hippocampal CA1 region. In this region, 1-3% of the grafted cells survived; and 3-9% of them expressed NeuN, a neuronal marker. Rats with more than 120 NeuN-positive cells showed partial improvement of impaired spatial learning in a water maze test. These results suggest that NSCs grafted in the ischemic brain are able to differentiate into neurons and to improve spatial recognition.

JNK activation is associated with intracellular beta-amyloid accumulation

c-Jun has been implicated in the pathogenesis of Alzheimer's disease (AD), but the upstream cascade leading to c-Jun activation in AD is not known. Activation of c-Jun N-terminal kinase (JNK) is obviously a candidate for the upstream event. We tested this possibility focusing on PS1-linked AD. First, we observed that JNK is actually activated in cerebral neurons of PS1-linked AD patients, using immunohistochemistry and Western blot analyses with anti-activated JNK antibodies. We analyzed the relationship between beta-amyloid (beta A) and JNK activation by using aged transgenic mice overexpressing mutant (M146L) PS1 and human AD brains. The mice showed no neuronal loss but a very few diffuse beta A deposits, corresponding to the early stage of PS1-linked AD brain. Some neurons were reactive for anti-beta A antibodies in the cerebral cortex. Interestingly, JNK activation was observed in neurons showing intracellular beta A immunoreactivity in transgenic mice. Association between intracellular beta A and JNK activation was confirmed in cortical neurons of sporadic and PS1-linked AD patients. Furthermore, introduction of beta A peptides into the primary culture cortical neurons induced JNK activation and cell death. Collectively, these results suggested that intracellular beta A accumulation might trigger JNK activation leading to neuronal death.

Haemopoietic biglycan produced by brain cells stimulates growth of microglial cells

We have recently found that soluble biglycan purified from rat thymic myoid cells had haemopoietic activity capable of inducing preferential growth and differentiation of monocytic lineage cells from various haemopoietic sources, including brain microglial cells. In the present study, to understand developmental mechanisms of microglial/monocytic cells in the brain, we have attempted to identify haemopoietic activity of the brain biglycan. The mRNA and the immunological epitope of biglycan were detected in the rat brain homogenates and several rat glial cell lines. Immunohistochemical study showed that several different types of brain cells produced biglycan. During development biglycan synthesis in the brain appeared to be increased. The brain haemopoietic biglycan was easily separated by DEAE-Sepharose chromatography from the macrophage colony stimulating factor (M-CSF) which was concomitantly produced from the brain cells. The brain haemopoietic biglycan, purified through immunoaffinity column, indeed stimulated growth of primarily cultured microglial cells. Taken together, these results suggest that the haemopoietic biglycan plays an important role in generating brain-specific circumstances for development of microglial/monocytic cells.

Analysis of lymphoproliferative cytokines produced by thymic myoid cells

Lymphoproliferative activities produced by cloned thymic myoid cell 871207B were analysed by immunological and biochemical methods. The lymphoproliferative activities were separated into two fractions by DEAE-Sepharose CL-6B chromatography: one is in the fraction passed through the column and the other in the fraction eluated from the column with a low concentration of NaCl. The eluated fraction induced the proliferation of interleukin-1 (IL-1)-dependent D10N4 M cells. This activity was abrogated by an anti-IL-1 alpha antibody, but not an anti-IL-1 beta antibody. Expression of IL-1 alpha mRNA was also detected in 871207B cells. The thymocyte proliferative activity found in the fraction passed through the DEAE-Sepharose column was further separated into three fractions by heparin-Sepharose column chromatography: (1) the fraction passed through the column, (2) the fraction weakly bound to the column, and (3) the fraction firmly bound to the heparin column. The fraction passed through the heparin column sustained the growth of IL-6-dependent MH60.BSF-2 cells. IL-6-specific mRNA was found in 871207B cells. The thymocyte proliferative activity of the fraction firmly bound to the heparin column was neutralized with an anti-IL-7 antibody. The biological activity of the fraction weakly bound to the column remained to be elucidated. These results suggest that thymic myoid cells produce IL-1 alpha, IL-6, IL-7 and unidentified lympho-stimulatory factors, all of which play significant roles in many steps of T-cell development in the thymus.

Transformations of Penicillium islandicum and Penicillium frequentans that produce anthraquinone-related compounds

Wild-type strains of Penicillium islandicum and Penicillium frequentans, which produce anthraquinone and related compounds, were transformed to benomyl and hygromycin B resistance. Plasmids pSV50 and pBT6, with benomyl-resistant beta-tublin genes, and plasmids pAN7-1 and pDH25, with a bacterial hygromycin phosphotransferase gene under the control of Aspergillus nidulans sequences, were used respectively. Transformation frequencies with these plasmids were 10-20 transformants per micrograms of DNA per 4-8 x 10(7) viable protoplasts. Integration of plasmid DNAs into chromosomal DNAs was confirmed by Southern-blot analysis. Copy numbers and sites of integration varied among transformants. The integrated plasmid DNAs conferring a drug-resistant phenotype were mitotically stable with or without selection. The demonstration of such transformation systems in the essential first step in the application of recombinant DNA technology to study the biosynthetic genes of anthraquinone and related compounds in P. islandicum and P. frequentans.

Immunological and biochemical characterization of biglycan-like haemopoietic factor

Immunological and biochemical characteristics of a 100,000 MW biglycan-like haemopoietic factor, purified from thymic myoid cells 871207B, were studied to distinguish them from macrophage colony-stimulating factor (M-CSF), which they resemble in activity and biochemical properties. Rabbit antibody raised against a synthetic peptide fragment (J-1) designed from amino acid sequences specific to the 100,000 MW factor responded to 871207B cells, the conditioned medium of 871207B, and capillary-like structures in the thymus, but not to M-CSF producer L-929 cells or the conditioned medium of L-929 cells. In contrast, M-CSF epitope was detected in L-929 cells and the conditioned medium cells but not in 871207B cells or the conditioned medium, even after enzymatic digestion of glycosaminoglycan chains. Treatment of the 100,000 MW factor with chondroitinase ABC and AC produced a 50,000 MW component. Digestion of this product with N-glycanase resulted in a 40,000 MW protein component. These results suggest that the 100,000 MW factor is a proteoglycan consisting of a core protein with an apparent molecular mass of 40,000 MW, a 50,000 MW chondroitin sulphate chain and 10,000 MW N-linked oligosaccharide chains. A small amount of a 40,000 MW monocytic cell growth activity was also found in the 871207B cell-conditioned medium. An enzymatically obtained 40,000 MW factor, the conditioned medium 40,000 MW factor, and the 100,000 MW factor were specifically eluated from an anti-J-1 IgG-immobilized affinity column with monocytic cell growth activity, suggesting that the biological activity resides in the 40,000 MW core protein. The 100,000 MW factor induced the proliferation and differentiation of monocytic lineage cells from a variety of sources, such as bone marrow cells, peritoneal exudated cells and brain microglia cells.

Action of a nuclease from rat nuclei on UV-irradiated DNA

An Mg(2+)-dependent nuclease was highly purified from rat-liver nuclei. The nuclease activity was enhanced in ultraviolet light (UV)-irradiated dsDNA, but not in unirradiated dsDNA. Irrespective of UV irradiation, ssDNA was readily cleaved by this enzyme. UV-irradiated plasmid DNA was incubated with this enzyme and subjected to the template primer activity assay with a Klenow polymerase. With increasing incubation time, the activity was enhanced in the circular-relaxed and linear forms, but not in the superhelical form. These results implied that this enzyme excises UV-damaged sites in dsDNA to form single strand gaps for repair synthesis.

Vasorelaxant and hypotensive effects of tilisolol hydrochloride (N-696) in isolated rat thoracic aorta and pithed rats

Vasorelaxant and hypotensive effects of tilisolol hydrochloride (N-696) in isolated rat thoracic aorta and pithed rats were investigated. In rat thoracic aorta pre-contracted with KCl (20 mM), tilisolol (10(-5)-10(-3) M) produced concentration-related relaxation, but nadolol and atenolol did not significantly inhibit the responses to 20 mM KCl. The concentration-relaxation curve of tilisolol underwent rightward parallel shifts only to a limited extent in the presence of glibenclamide, a specific antagonist of K+ channel openers. Glibenclamide also shifted the concentration-relaxation curve of cromakalim to the right and in a parallel manner, whereas it did not change that of propranolol. In pithed rats, tilisolol (0.5-2.0 mg/kg, i.v.), but neither nadolol nor atenolol, caused a dose-dependent decrease in diastolic blood pressure and a slight increase in heart rate. Following treatment of the preparation with glibenclamide, the hypotensive effects of tilisolol and cromakalim were antagonized, while that of propranolol was not affected. These results suggest that the vasorelaxant and hypotensive actions of tilisolol involve an opening of K+ channels which can be inhibited by glibenclamide and may also involve additional relaxant mechanisms of action independent of K+ channel opening.

Bending of a highly repetitive component in rat nuclear DNA

A highly repetitive component in rat nuclear DNA was isolated by HindIII digestion and cloned. A 370-bp cloned component was highly AT-rich (68.3%) in about one third of the region from the 3'-terminus and showed an anomalously slow gel electrophoretic mobility (k-factor = 1.19). These results indicated that a sequence-directed bending of the helix axis occurs in the component. Accordingly, a subclone containing a tandem dimer of the component was isolated and subjected to a circular permutation analysis for exploring the bend center (1). In consequence, the center was shown to be present in the sequence ranging from position near 270 to the 3'-terminus and estimated to be located around position 340.

A nuclease from rat-liver nuclei with endo- and exonucleolytic activity

An Mg2(+)-dependent endonuclease endogenous to rat-liver nuclei had an exonuclease activity for single-stranded DNA, but not for duplex DNA. The activity was about twice as high in the 3'----5' direction as in the 5'----3' direction. The products by 3'----5' activity were mononucleotides alone. The 5'----3' activity released mononucleotides as main products and small amounts of di-, tri-, tetra- and oligonucleotides. Another major endonuclease endogenous to the nuclei, a Ca2+/Mg2(+)-dependent endonuclease, did not have such exonuclease activities.

Base sequences of highly repetitive components in nuclear DNAs from rat liver and rat-ascites hepatoma

A 370-bp highly repetitive component in each of the nuclear DNAs from rat liver (RL) and rat-ascites hepatoma (AH) was isolated by HindIII digestion and cloned in pUC9. Ten of the resulting clones were arbitrarily selected and sequenced. Heterogeneity of size was found in 7 of the RL clones (366-369 bp), but in only 2 of the AH clones (369 bp). The sequence homology was 64.6% among the RL clones; 80.3% among the AH clones. The base compositions were AT-rich, ranging from 61.1% to 64.7%. Many A and/or T runs consisting of 2-5 bases were interspersed throughout each sequence. The restriction sites reported previously, EcoRI, HaeIII, HindIII, HinfI and HphI sites, were confirmed in almost all of the clones. In the present experiment, 12 kinds of the sites were further found in both RL and AH clones.

Affinity of a DNA with highly repetitive sequence for nuclear proteins from rat liver

A nuclear scaffold fraction (designated P fraction elsewhere) comparable to a nuclear matrix was prepared from rat liver. This fraction was composed mainly of 45-49 kDa proteins and high-molecular-weight proteins (more than 90 kDa). In addition, a 370-bp repetitive sequence DNA fragment was derived predominantly from the EcoRI digest of the deproteinized P fraction. By an immunoblot affinity assay with the P fraction, the fragment was shown to have affinity for each of the 107- and 115-kDa proteins. Moreover, by a filter binding assay with a mixture of these proteins, the affinity level was estimated to be about 6 times as high in the native (double-stranded) fragment as in the denatured (single-stranded) fragment.