Gastritis cystica profunda in an unoperated stomach mimicking a pyloric submucosal tumor and causing anorexia: A case report and literature review.

BACKGROUND: Gastritis cystica profunda (GCP), commonly observed in remnant gastric anastomosis, is associated with developing gastric cancer. CASE: This case report describes a patient with GCP in a previously unoperated stomach that mimicked a pyloric submucosal tumor and caused anorexia, which is rare in clinical practice. PATIENT CONCERNS: A 72-year-old woman presented with loss of appetite and weight. DIAGNOSES: Gastroscopy detected a 20 mm diameter submucosal tumor near the pylorus. Computed tomography and magnetic resonance imaging identified a cystic lesion, unlike a usual submucosal tumor in the stomach. The diagnosis was difficult, even with endoscopic ultrasound-guided fine-needle aspiration. INTERVENTIONS: Surgery was performed for diagnosis and treatment. The lesion was resected using a submucosal dissection technique after an incision of the gastric wall during open laparotomy. Histopathological examination confirmed the diagnosis of GCP and revealed no dysplasia or cancer. OUTCOMES: Anorexia resolved after the surgery. Residual or recurrent lesions were not detected during follow-up examinations performed 1 year after surgery. LESSONS: GCP occurring in a previously unoperated stomach as a macroscopic lesion like a submucosal tumor causing some symptoms is rare. GCP is associated with a risk of developing cancer. Therefore, careful evaluation and management during treatment are required.

Laparoscopic resection for appendiceal mucocele secondary to endometriosis: A case report.

INTRODUCTION: This case report describes a patient who underwent laparoscopic resection of the mucocele of the appendix secondary to endometriosis, a rarity in clinical practice. PATIENT CONCERNS: The patient was a 38-year-old woman with a history of endometriosis and an ovarian cyst who sought medical advice with a chief complaint of mild right lower abdominal pain. DIAGNOSES: Computed tomography and ultrasonography of the abdomen revealed a cystic lesion at the distal end of the appendix without definitive findings of malignancy. Colonoscopy revealed a submucosal tumor-like elevation at the appendiceal orifice. Appendiceal mucocele was suspected preoperatively. INTERVENTIONS: The lesion was resected laparoscopically. Secondary ileocecal resection with lymphadenectomy was possible if the resected specimen was pathologically diagnosed as a malignant tumor with the risk of lymph node metastasis. OUTCOMES: The resected specimen was pathologically diagnosed as an appendiceal mucocele secondary to endometriosis; therefore, additional surgery was avoided. CONCLUSION: Although appendiceal mucoceles secondary to endometriosis are rare, laparoscopic surgery in which only the lesion was resected is a useful strategy for the treatment and pathological diagnosis of appendiceal mucoceles without findings of malignancy.

Impact of Subclassification of Serosal Invasion on the Survival of Patients With T4a Gastric Cancer.

BACKGROUND/AIM: In the Japanese Classification of Gastric Carcinoma, T4a gastric cancer is defined as tumor invasion contiguous to the serosa or penetrating the serosa with exposure to the peritoneal cavity. The aim of this study was to assess the impact of T4a subclassification of gastric cancer on survival. PATIENTS AND METHODS: A total of 326 patients with T4a cancer who had undergone gastrectomy were enrolled. The T4a tumors were classified into two groups: serosa-contiguous or serosa-exposed. RESULTS: The serosa-exposed group had a significantly worse prognosis, and multivariate analysis identified the T4a subclass as an independent prognostic factor. Analysis of the risk factors for recurrence identified the T4a subclass as a significant risk factor for peritoneal recurrence in patients undergoing curative gastrectomy. CONCLUSION: The serosa-contiguous and serosa-exposed subgroups of T4a gastric cancer showed different biological behaviors. These groups may need to be treated as separate.

Clinicopathological Role of Vasohibin in Gastroenterological Cancers: A Meta-Analysis.

Vasohibin-1 (VASH1) is an angiogenesis inhibitor, while vasohibin-2 (VASH2) is a proangiogenic factor. The roles of VASH1 and VASH2 expression in gastroenterological cancers remain unclear. We searched for relevant literature, specifically studies on gastroenterological cancer, and evaluated the relationship between VASH expression and clinical outcomes. Nine studies on VASH1 involving 1,574 patients were included. VASH1 expression was associated with the TNM stage [OR (odds ratio) 2.05, 95% CI (confidence interval) 1.24-3.40], lymph node metastasis (OR 1.79, 95% CI 1.24-2.58), lymphatic invasion (OR 1.95, 95% CI 1.41-2.68), and venous invasion (OR 2.49, 95% CI 1.60-3.88); poor clinical outcomes were associated with high VASH1 expression. High VASH1 expression was associated with a significantly shorter overall survival (OS) [HR (hazard ratio) 1.69, 95% CI 1.25-2.29] and disease-free survival (DFS) (HR 2.01, 95% CI 1.28-3.15). Three studies on VASH2 involving 469 patients were analyzed. VASH2 expression was associated with the TNM stage (OR 4.21, 95% CI 1.89-9.51) and venous invasion (OR 2.10, 95% CI 1.15-3.84); poor clinical outcomes were associated with high VASH2 expression. High VASH2 expression was associated with a significantly lower OS (HR 1.61, 95% CI 1.09-2.37). In conclusion, high VASH1 and VASH2 expression levels were associated with poor clinical outcomes and prognosis in patients with gastroenterological cancers.

Usefulness of Five-Parameter System Reconfirmed for Cytopathology of Oral Squamous Cell Carcinoma regardless of Differentiation Degree.

BACKGROUND: We previously introduced the Five-Parameter System (FPS), which exclusively evaluates keratinized cellular findings, for use in cytology examinations of oral well-differentiated squamous cell carcinoma (SCC) and carcinoma in situ (CIS) specimens, as they occasionally lack nuclear atypia and can be challenging for categorization by The Bethesda System (TBS). This study was conducted to determine whether FPS parameters are detectable even in oral SCC/CIS specimens with apparent nuclear atypia. SUMMARY: Oral cytology specimens were obtained together with biopsy tissue samples. They were obtained from 59 malignant (HSIL and SCC) and 29 not-definitely malignant (NILM to ASC-H) specimens diagnosed using TBS. Following re-confirmation of the original TBS categorization, the specimens were re-evaluated using FPS. One or more of the FPS parameters were noted in 69 of 70 malignant specimens examined, of which 11 had been diagnosed by TBS as not-definitely malignant. The remaining one malignant specimen was diagnosed as SCC with only TBS. FPS parameters #1 (concentric arrangement), #2 (large cell number), #3 (bizarre-shaped cells), #4 (keratoglobules), and #5 (uneven filamentous cytoplasm) were observed only in malignant cases, while none were revealed in not-definitely malignant specimens. Finally, TBS supplemented with FPS achieved sensitivity, specificity, accuracy, positive predictive value, and negative predictive value of 100%. KEY MESSAGES: FPS parameters are included in most examinations of oral cytology specimens. Thus, FPS is highly recommended for use in cytology examinations of oral SCC regardless of differentiation degree to confirm judgment based on TBS, a mandatory standard, as well as to cover its limitation of mainly evaluating nuclear atypia. FPS is considered to be an important diagnostic tool for oral cytology, especially in triage cases, which are challenging for TBS. Cytopathology should not be limited to only nuclear findings but be based on whole-cell morphology.

Small bowel obstruction caused by a true ileo-ileal knot: a rare case successfully treated by prior ligation of mesenteric vessels.

BACKGROUND: Intestinal knot formation, in which two segments of the intestine become knotted together, can result in intestinal obstruction. An ileo-ileal knot refers to knot formation between two ileal segments and is a very rare benign disease. We report a case of strangulated bowel obstruction caused by true ileo-ileal knot formation. CASE PRESENTATION: An 89-year-old woman was referred to our hospital with the diagnosis of intestinal obstruction. Contrast-enhanced computed tomography revealed the small bowel forming a closed loop, with poor contrast effect. Based on the findings, the patient was diagnosed as having strangulated bowel obstruction, and emergency surgery was performed. At laparotomy, two segments of the ileum were found to be tied together forming a knot, and both segments were necrotic. Although it was necessary to release the strangulated small bowel, we did not immediately release the knot, but first proceeded with ligation of the mesenteric vessels to the strangulated small bowel to prevent dissemination of toxic substances from the necrotic bowel into the systemic circulation. The surgery was completed with resection of the necrotic ileum and anastomosis of the small intestine. The postoperative course was uneventful, and the patient was discharged home. CONCLUSION: We encountered a case of strangulated bowel obstruction caused by true ileo-ileal knot formation. Resection of the necrotic small intestine without releasing the knot could be performed safely, and might be considered as an option of surgical procedure.

Successful laparoscopic surgery combined with selective arterial embolization for bleeding due to jejunal angiodysplasia: a case report.

BACKGROUND: Angiodysplasia of the gastrointestinal tract is a rare vascular pathology that sometimes causes massive hemorrhage. Angiodysplasias are particularly difficult to find in the small intestine for anatomical reasons, often impeding their diagnosis and treatment. Lesion localization is a major challenge in cases of small bowel bleeding requiring surgical intervention. CASE PRESENTATION: The present case was a 52-year-old woman who was urgently hospitalized with repeated tarry stools. Surgical intervention was chosen after conservative treatment failed to improve her condition. The source of bleeding was suspected to be a vascular lesion discovered in the small intestine during a past double-balloon endoscopy. Abdominal contrast computed tomography revealed a jejunal hemorrhage. We chose selective arterial embolization to stabilize her hemodynamics followed by surgical intervention as her treatment plan. Several embolic and contrast agents (cyanoacrylate, indigo carmine, and Lipiodol) were combined to help identify the location of the lesion during surgery. This multi-pronged approach allowed us to localize the lesion under laparoscopic guidance with high confidence and accuracy, and to excise a 6-cm segment of the small intestine. The lesion was histologically diagnosed as angiodysplasia. No re-bleeding has been observed since the operation. CONCLUSION: We report our experience with a case of jejunal angiodysplasia, which was localized with selective arterial embolization using an array of embolic and contrast agents, and then excised laparoscopically. Selective arterial embolization with indigo carmine dye to treat small bowel bleeding preoperatively not only makes the surgery safer by stabilizing the patient's hemodynamics, but is also very useful for localizing the lesion intraoperatively.

Prognostic significance of vasohibin-1 and vasohibin-2 immunohistochemical expression in gastric cancer.

PURPOSE: It was recently identified that the vasohibin family may regulate angiogenesis through suppression by the vasohibin-1 gene and promotion by the vasohibin-2 gene. We assessed vasohibin expression in gastric cancer patients and its effect on their prognosis. METHODS: We evaluated vasohibin immunohistochemical expression in 210 patients with gastric cancer, who underwent radical surgery. The patients were divided first into a vasohibin-1-positive group and a vasohibin-1-negative group, and then into groups with high or low vasohibin-2 expression, to allow us to investigate the clinicopathological factors of prognosis retrospectively. RESULTS: There were 139 patients in the vasohibin-1-positive group and 71 patients in the vasohibin-1-negative group, among which there were and 108 with high vasohibin-2 expression and 102 with low vasohibin-2 expression. Vasohibin-1 was associated with Ly (P = 0.003) and pT (P = 0.037), whereas vasohibin-2 was associated with Ly (P < 0.001), V (P < 0.001) and pStage (P < 0.001). Overall, cancer-specific and relapse-free survival rates were lower in the vasohibin-1-positive (P = 0.034, P < 0.001, P = 0.002, respectively) and high vasohibin-2 expression (P = 0.004, P = 0.003, P < 0.001, respectively) groups. Multivariate analysis revealed that vasohibin-1 expression was associated with cancer-specific (P = 0.014, hazard ratio [HR] 4.454) and relapse-free (P = 0.035, HR 2.557) survival and vasohibin-2 expression tended to influence relapse-free survival (P = 0.051, HR 2.061). Grouping patients by vasohibin expression status combinations showed correlation among their expressions (P = 0.005). Overall, cancer-specific and relapse-free survival rates were lowest in the vasohibin-1-positive and high vasohibin-2 expression group. CONCLUSION: Our findings demonstrate that vasohibin-1 and vasohibin-2 could be novel biomarkers for predicting gastric cancer prognosis.

Plasma vasohibin-1 and vasohibin-2 are useful biomarkers in patients with esophageal squamous cell carcinoma.

BACKGROUND: Vasohibins (VASH), which are angiogenesis regulators, consist of Vasohibin-1 (VASH1) and Vasohibin-2 (VASH2). VASH1 is an angiogenesis inhibitor, while VASH2 is a proangiogenic factor. Patients with esophageal squamous cell carcinoma (ESCC) with high tumor expression levels of VASH1 and VASH2 have been reported to show a poor prognosis. The clinical significance of VASH concentrations in the blood of patients with ESCC has not yet been investigated. METHODS: Plasma samples from 89 patients with ESCC were analyzed, and the relationships between the plasma VASH concentrations and the clinicopathological factors of the patients were evaluated. Immunohistochemical examination (IHC) of the resected tumor specimens for VASH was performed in 56 patients, and the correlation between the plasma VASH concentrations and tumor expression levels of VASH was analyzed. RESULTS: The patient group with high plasma concentrations of VASH1 showed a higher frequency of lymph node metastasis (P = 0.01) and an invasive growth pattern (P = 0.05). Furthermore, poorly differentiated cancer occurred at a higher frequency in the patient group with high plasma concentrations of VASH2 (P < 0.01). High tumor expression levels of VASH1 were encountered more frequently in the patient group with high plasma concentrations of VASH1 (P = 0.03), and high tumor expression levels of VASH2 were encountered more frequently in the patient group with high plasma concentrations of VASH2 (P = 0.04). CONCLUSIONS: In patients with ESCC, high plasma concentrations were associated with poor clinical outcomes for both VASH1 and VASH2. We propose that results indicate that plasma VASH1 and VASH2 are useful biomarkers in patients with ESCC.

Clinical Implication of Tumor-invasive Status into the Muscularis Propria in T2 Gastric Cancer.

BACKGROUND/AIM: Several studies have investigated prognostic factors in patients with T2 gastric cancer, but no consensus has been reached to date. The aim was to investigate the clinicopathological significance of the status of tumor invasion into the muscularis propria (MP) in T2 gastric cancer patients. PATIENTS AND METHODS: A total of 113 patients with T2 cancer were enrolled. The status of caner invasion was analyzed according to width (extent of horizontal invasion) and depth (extent of vertical invasion). RESULTS: The prognosis of the group with wide width of invasion (≥1.5 cm) was significantly poorer than that of the group with narrow width of invasion (<1.5 cm) (p=0.001). Multivariate analysis identified the width, and not the depth, as an independent prognostic factor. The analysis according to AJCC N stage showed that the width, and not the nodal status, was an independent prognostic factor in the N2-N3 patients (p=0.005). CONCLUSION: Measurement of the width of tumor invasion into the MP was useful to understand the malignant potential of T2 gastric cancer.

[Paradoxical embolism due to right superior vena cava draining into the left atrium].

We report a forty-six-year-old man with a past history of brain abscess managed by surgical drainage and recurrent ischemic strokes. After treatment of brain abscess, he had been on medication for symptomatic epilepsy, but had ceased medication by his judgment. He was taken to a hospital in an ambulance for an epileptic seizure. In the hospital he suffered from drug-induced renal dysfunction caused by the intravenous anti-epileptic drug, and right hemiparesis due to ischemic stroke occurred on the third hospitalization day. He was transferred to our hospital to get a treatment for renal failure. His renal function improved gradually by hemodialysis, but an ischemic stroke recurred in the right cerebellar hemisphere. Closer examinations on the mechanisms of his strokes revealed the draining of right superior vena cava (RSVC) directly into the left atrium (LA), persistent left superior vena cava (PLSVC) and atrial septal defect (ASD). He had a rare anomaly of the systemic venous return. It seemed that his repeated strokes were caused by paradoxical embolism through the draining of RSVC to LA, and air or thrombi in the infusion lines other than intravenous thrombi was thought to be an embolic cause in this case.

[A Case of Advanced Neuroendocrine Cell Carcinoma of the Stomach Treated with S-1 and Cisplatin Chemotherapy].

A 69-year-old man presented to our hospital because of epigastric pain. A type 2 lesion was seen in the lesser curvature of the antrum of the stomach. A moderately differentiated adenocarcinoma(human epidermal growth factor receptor 2-negative) was diagnosed by biopsy. Abdominal computed tomography showed a mass shadow 52mm in diameter in the pyloric region invading the surrounding organs, but no evidence of distant metastasis. Chemotherapy with S-1 and cisplatin(SP therapy)was initiated because of a diagnosis of locally advanced gastric cancer. After 2 courses of chemotherapy, the tumor shrinkage rate was 70%, confirming that treatment was effective. However, severe skin disorders developed, precluding the continuation of chemotherapy. Staging laparoscopy showed no evidence of peritoneal dissemination, but invasion into the superior mesenteric vein was noted. The tumor was resected by pancreaticoduodenectomy with partial resection of the venous wall. Pathological examination of the resected specimens provided a definite diagnosis of neuroendocrine cell carcinoma. As of 1 year and 7 months after surgery, there has been no observation of metastasis or recurrence. SP therapy was suggested to be a useful regimen for preoperative chemotherapy in patients with locally advanced neuroendocrine cell carcinoma.

Differential diagnosis of well-differentiated squamous cell carcinoma from non-neoplastic oral mucosal lesions: New cytopathologic evaluation method dependent on keratinization-related parameters but not nuclear atypism.

BACKGROUND: The cytology of oral squamous cell carcinoma (SCC) is challenging because oral SCC cells tend to be well differentiated and lack nuclear atypia, often resulting in a false negative diagnosis. The purpose of this study was to establish practical cytological parameters specific to oral SCCs. METHODS: We reviewed 123 cases of malignancy and 53 of non-neoplastic lesions of the oral mucosa, which had been diagnosed using both cytology and histopathology specimens. From those, we selected 12 SCC and 4 CIS cases that had initially been categorized as NILM to ASC-H with the Bethesda system, as well as 4 non-neoplastic samples categorized as LSIL or ASC-H as controls, and compared their characteristic findings. After careful examinations, we highlighted five cytological parameters, as described in Results. Those 20 cytology samples were then reevaluated by 4 independent examiners using the Bethesda system as well as the 5 parameters. RESULTS: Five cytological features, (i) concentric arrangement of orangeophilic cells (indicating keratin pearls), (ii) large number of orangeophilic cells, (iii) bizarre-shaped orangeophilic cells without nuclear atypia, (iv) keratoglobules, and (v) uneven filamentous cytoplasm, were found to be significant parameters. All malignant cases contained at least one of those parameters, while none were observed in the four non-neoplastic cases with nuclear atypia. In reevaluations, the Bethesda system did not help the screeners distinguish oral SCCs from non-neoplastic lesions, while use of the five parameters enabled them to make a diagnosis of SCC. CONCLUSION: Recognition of the present five parameters is useful for oral SCC cytology. Diagn. Cytopathol. 2017;45:406-417. © 2017 Wiley Periodicals, Inc.

The first case of huge amebic intra-abdominal tumor with asymptomatic amebic colitis.

We report a rare case of huge amebic intra-abdominal tumor with asymptomatic amebic colitis. This appears to represent the first report of amebic intra-abdominal tumor. A 31-year-old woman presented to a local doctor with only a sensation of abdominal fullness. Abdominal computed tomography (CT) showed a huge intra-abdominal tumor in the left abdominal cavity, and she was referred to our hospital. Colonofiberscopy for detailed examination showed multiple slight, discrete ulcers in the cecum. Ameboid trophozoites were identified from biopsy specimens, and asymptomatic amebic colitis was diagnosed. Oral metronidazole (MTZ) was administered at 1500 mg/day for 10 days. CT 14 days after starting MTZ showed no change in the intra-abdominal tumor, and resection of the tumor was therefore performed. Pathological examination revealed Entamoeba histolytica with engulfed erythrocytes complicated by hemorrhagic cyst. If an intra-abdominal tumor is present and colitis is observed, amebic intra-abdominal tumor should be considered among the differential diagnoses.

Comparison between early enteral feeding with a transnasal tube and parenteral nutrition after total gastrectomy for gastric cancer.

BACKGROUND/AIMS: This retrospective study evaluated 21 patients with early enteral feeding (EEF group) and 22 patients without early enteral feeding (non-EEF group) who underwent open total gastrectomy followed by Roux en Y reconstruction and were RO resectable cases. METHDOLOGY: Postoperative complications and course, postoperative/preoperative body weight, whole meal intake, and nutritional, inflammatory, and immunological parameters were recorded and evaluated in both groups. RESULTS: Postoperative meal intake was significantly higher and the first day of defecation was significantly earlier in the EEF group than in the non-EEF group. There were no significant differences between the 2 groups in the blood laboratory data and the rate of complications. In patients with complications, lymphocyte counts and postoperative body weights were compared as indicators of immunostimulation. The lymphocyte counts 7 days after operation and postoperative/preoperative body weight were significantly higher in the EEF group than in the non-EEF group. CONCLUSIONS: Although immunostimulation-like findings were observed in the patients with complications after surgery in the present study, the significance of EEF was not clarified because of the lack of cases whose conditions were severe. EEF should be used especially for patients in whom severe disease is possible and avoidance of TPN is desirable.

Carotid artery dissection associated with an elongated hyoid bone.

A 36-year-old man presented with acute cerebral infarction in the right frontal lobe associated with right internal carotid artery dissection (CAD). Enhanced computed tomography revealed right greater horn of the hyoid bone in close proximity to the right internal carotid artery (ICA). It was speculated that mechanical compression of the internal carotid artery by the hyoid bone induced by neck rotation was related to ICA dissection. Greater knowledge of the association between the hyoid bone and the CAD will lead to increased awareness and appropriate diagnosis.

Cross-sectional and prospective study of the association between lung function and prediabetes.

OBJECTIVES: A growing body of evidence suggests that there is a relationship between impaired lung function and the risk of developing diabetes mellitus (DM). However, it is not known if this reflects a causal effect of lung function on glucose metabolism. To clarify the relationship between lung function and the development of DM, we examined the incidence of newly diagnosed prediabetes (a precursor of DM) among subjects with normal glucose tolerance (NGT) at baseline. DESIGN: Primary analysis of an occupational cohort with both cross-sectional and longitudinal data (follow-up duration mean±SD: 28.4±6.1 months). SETTING AND PARTICIPANTS: Data were analysed from 1058 men in a cross-sectional study and from 560 men with NGT in a longitudinal study. OUTCOMES AND METHODS: Impaired lung function (per cent predicted value of forced vital capacity (%FVC) or per cent value of forced expiratory volume 1 s/FVC (FEV(1)/FVC ratio)) in relation to the ratio of prediabetes or DM in a cross-sectional study and development of new prediabetes in a longitudinal study. NGT, prediabetes including impaired glucose tolerance (IGT) and increased fasting glucose (IFG) and DM were diagnosed according to 75 g oral glucose tolerance tests. MEASUREMENTS AND MAIN RESULTS: %FVC at baseline, but not FEV(1)/FVC ratio at baseline, was significantly associated with the incidences of DM and prediabetes. Among prediabetes, IGT but not IFG was associated with %FVC. During follow-up, 102 subjects developed prediabetes among those with NGT. A low %FVC, but not FEV(1)/FVC ratio, was predictive of an increased risk for development of IGT, but not of IFG. CONCLUSIONS: Low lung volume is associated with an increased risk for the development of prediabetes, especially IGT, in Japanese men. Although there is published evidence for an association between chronic obstructive pulmonary disease and DM, prediabetes is not associated with the early stage of COPD.

Depression risks in mothers of children with developmental disabilities: a cross-cultural comparison of Brazil, Colombia, Malaysia and Thailand.

BACKGROUND: Compared with US or European countries, there are fewer mental health services for mothers of children with developmental disabilities in Latin American and/or Southeast Asian countries. AIMS: To explore the risk of depression in mothers of children with developmental disabilities in countries with a lack of mental health professionals, we conducted cross-cultural comparisons for four countries: Brazil, Colombia, Malaysia and Thailand. METHODS: Using the CES-D, we compared the participants' depressive symptoms, by which we also estimated the probability of morbid depression. RESULTS: In every country, participants tended to show depressive symptoms. In the CES-D total scores and the numbers of mothers who were observed to have a high level of depressive symptoms, there were significant differences among countries (F = 4.36, p = .006; χ2 = 10.3, p = .015). CONCLUSIONS: Considering cultural models, we could apply evidence-based intervention to depressive mothers of children, and conduct intervention and treatment for those mothers and evaluate ways of providing better mental health services to these individuals.

[Case of an elderly patient with community acquired bacterial meningitis due to extended spectrum ß lactamase producing Escherichia coli].

Community acquired bacterial meningitis due to extended spectrum ß lactamase-producing Escherichia coli is very rare. We report the case of a 72-year-old woman being treated for longstanding diabetes mellitus. She developed lower back pain accompanied by elevated body temperature, and was transported to the emergency unit in our hospital five days later because of impaired consciousness. An abdominal plane CT showed acute pyelonephritis and a brain MRI showed inflammatory exudate in the posterior horn of her bilateral ventricles. A lumbar puncture was performed, and examination of the cerebrospinal fluid revealed a marked elevation in her cell count (polymorphonuclear leukocytes dominant) that we diagnosed as bacterial meningitis. Initially, she was treated with intravenous meropenem, ceftriaxon, and vancomycin. Extended spectrum ß lactamase-producing Escherichia coli were then detected in her urinary and blood cultures, and the antibiotics were changed to intravenous meropenem, gentamicin, and intrathecal gentamicin. Her clinical symptoms improved, but her inflammatory reaction was prolonged and we detected spondylitis. She was then treated with levofloxacin, and the inflammatory reaction improved. Extended spectrum ß lactamase-producing Escherichia coli should be taken into consideration as a cause of community acquired bacterial meningitis.

Cytological features of atypical carcinoid combined with adenocarcinoma of the uterine cervix.

Neuroendocrine tumors of the uterine cervix (UC) are rare, and atypical carcinoid (AC) combined with adenocarcinoma of the uterine cervix (ACAUC) is particularly rare. Only the histopathology has been investigated in the English literature. A 49-year-old female with a polypoid lesion of the UC visited Yamanashi Prefectural Central Hospital. Scraping cytology, biopsy, and hysterectomy was performed. EC smears showed solid, rosette, honeycomb,true tubular, and trabecular clusters. Solid clusters were oval, thin-edge, delicate, small-large nuclei, pale, granular, scant, nothing,and well-preserved (though ill-defined border) cytoplasm. Rosette clusters were eccentric, oval nuclei, mixture of coarsely granular chromatin and euchromatin, and cyanophilic luminal content. Solid and rosette clusters impress AC. Honeycomb clusters involved a clearly defined border and translucent mucin. True tubular clusters were oval nuclei of fine chromatin or euchromatin, thick cytoplasm,and orange luminal content. Honeycomb and true tubular clusters suspected adenocarcinoma. Trabecular clusters were fusiform, columnar, cuboidal, and polygonal cell shapes of small,monotonous nuclei, and contained coarsely granular chromatin with occasionally intracytoplasmic translucent mucin and were difficult to differentiate typical carcinoid and adenocarcinoma.Histology was AC combined with adenocarcinoma. The aim of this study was to investigate the cytological characteristics of ACAUC.