A non-HIV case with disseminated Mycobacterium kansasii disease associated with strong neutralizing autoantibody to interferon-γ.

Disseminated non-tuberculous mycobacterium (dNTM) infection is rare in humans without human immunodeficiency virus (HIV) infection. Previous reports have shown autoantibodies to human interferon-gamma (IFN-γ), which play important roles in mycobacterium infection, in the sera of patients with non-HIV dNTM disease. Herein, we describe a 53-year-old male who was strongly suspected to have multicentric Castleman disease (MCD) based on bone marrow study and chest radiological findings. However, Mycobacterium kansasii was detected in respiratory samples including pleural effusion. We initiated anti-mycobacterial therapy under intensive care; he died on the 48(th) hospital day. We detected no hematological disorders, ruling out MCD postmortem. However, we detected M. kansasii in pulmonary, liver, spleen and bone marrow tissues. Moreover, anti-IFN-γ autoantibody was detected with strong neutralizing capacity for IFN-γ. We consider our present report to contribute to understanding of the relationship between anti-IFN-γ autoantibody and disease development.

The effects of an AMPA receptor antagonist on the neurotoxicity of tetracaine intrathecally administered in rabbits.

We have reported that large concentrations of intrathecal local anesthetics increase glutamate concentrations in the cerebrospinal fluid (CSF) and cause neuronal injury in rabbits. In the current study we determined whether an alpha-amino-3-hydroxy-5-methylisoxazole-4-propionic acid (AMPA) receptor antagonist, YM872, administered intrathecally, reduces neuronal injury caused by tetracaine. We first examined the effects of intrathecal YM872 10, 30, 100, or 300 mug in rabbits (n = 3 in each). YM872 produced reversible motor and sensory block in a dose-dependent manner. Then, we evaluated modulatory effects of YM872 (300 mug) on tetracaine-induced glutamate release and neuronal injury. Pretreatment of YM872 did not attenuate 1% or 2% tetracaine-induced increases in cerebrospinal fluid glutamate concentrations (n = 3 in each). For evaluation of neuronal injury, rabbits were assigned to 4 groups (n = 6 in each) and intrathecally received 1% tetracaine and saline (1%T), 1% tetracaine and YM872 (1%TY), 2% tetracaine and saline (2%T), or 2% tetracaine and YM872 (2%TY). The volume of saline, YM872, and tetracaine was 0.3 mL. Saline or YM872 was administered 30 min before tetracaine administration. Neurological and histopathological assessments were performed 1 wk after the administration. Two and 1 animals respectively, showed motor and sensory dysfunction in 1%T, whereas 5 animals showed both motor and sensory dysfunction in 2%T. YM872 improved 2% tetracaine-induced motor dysfunction and neuronal damage (chromatolytic neurons, identified by round-shaped cytoplasm with loss of Nissl substance from the central part of the cell and eccentric nuclei). In 2%TY, 3 animals showed normal motor function and 3 showed mild dysfunction (ability to hop, but not normally), whereas 4 animals showed moderate dysfunction (inability to hop) in 2%T (P = 0.042). Only 2 animals showed one chromatolytic neuron in 2%TY, whereas 5 animals showed 4-16 chromatolytic neurons in 2%T (P = 0.020). These results suggest that AMPA receptor activation is involved, at least in part, in the tetracaine-induced neurotoxicity in the spinal cord.

Changes in the bispectral index during intraabdominal irrigation in patients anesthetized with nitrous oxide and sevoflurane.

Surgical stimulation typically results in an activation of electroencephalographic activity. In some instances, painful stimulation in the presence of inadequate anesthesia results in a suppression of the electroencephalogram. This phenomenon has been referred to as a "paradoxical arousal." In our daily practice, we have noted a marked decrease in the bispectral index (BIS) with large delta waves during abdominal surgery when the abdominal cavity was irrigated with normal saline. In the present study, we sought to evaluate changes in BIS during intraabdominal irrigation. Eighteen ASA physical status I-II patients scheduled for elective abdominal surgery were enrolled in the study and allocated randomly to the control group (group C) or the fentanyl group (group F). Anesthesia was induced with 3 mg/kg of thiopental and was maintained with sevoflurane and 50% nitrous oxide. BIS, 95% spectral edge frequency (SEF95), and burst-suppression ratio were recorded using a BIS monitor. Near the end of the procedure, but before irrigation of the abdominal cavity, 1.5 microg/kg fentanyl was given IV to group F. There was no significant change in BIS or SEF95 in group F patients during subsequent irrigation of the abdominal cavity. In contrast, BIS and SEF95 decreased significantly after start of irrigation in group C patients. These data show that the stimulation occurring during intraabdominal irrigation might cause a paradoxical arousal response, as evidenced by a decrease in processed electroencephalographic parameters. Pretreatment with fentanyl suppressed these changes. Anesthesiologists should be aware of this paradoxical arousal response to avoid an inappropriate decrease in the anesthetic concentration in such situations.

The relationship between bispectral index and electroencephalographic parameters during isoflurane anesthesia.

UNLABELLED: Bispectral index (BIS) integrates various electroencephalographic (EEG) parameters into a single variable. However, the exact algorithm used to synthesize the parameters to BIS values is not known. The relationship between BIS and EEG parameters was evaluated during nitrous oxide/isoflurane anesthesia. Twenty patients scheduled for elective ophthalmic surgery were enrolled in the study. After EEG recording with a BIS monitor (A-1050) was begun, general anesthesia was induced and maintained with 0.5%-2% isoflurane and 66% nitrous oxide. Using software we developed, we continuously recorded BIS, spectral edge frequency 95% (SEF95), and EEG parameters such as relative beta ratio (BetaRatio), relative synchrony of fast and slow wave (SynchFastSlow), and burst suppression ratio. BetaRatio was linearly correlated with BIS (r = 0.90; P < 0.01; n = 253) at BIS more than 60. At a BIS range of 30 to 80, SynchFastSlow (r = 0.60; P < 0.01; n = 3314) and SEF95 (r = 0.75; P < 0.01; n = 3339) were linearly correlated with BIS. The correlation between BIS and SEF95 was significantly better than the correlation between BIS and SynchFastSlow (P < 0.01). At BIS less than 30, the burst suppression ratio was inversely linearly correlated with BIS (r = 0.76; P < 0.01; n = 65). At BIS less than 80, burst-compensated SEF95 was linearly correlated with BIS (r = 0.78; P < 0.01; n = 3404). In the range of BIS from 60 to 100, BIS can be calculated from BetaRatio. At surgical levels of anesthesia, BIS and SynchFastSlow (a parameter derived from bispectral analysis) or burst-compensated SEF95 (derived from power spectral analysis) are well correlated. However, our results show that SynchFastSlow has no advantage over SEF95 in calculation of BIS. IMPLICATIONS: The relationship between bispectral index (BIS) and electroencephalographic parameters was evaluated during nitrous oxide/isoflurane anesthesia. At surgical levels of anesthesia, BIS and the relative synchrony of fast and slow wave (a parameter derived from bispectral analysis) or burst-compensated spectral edge frequency 95% (a parameter derived from power spectral analysis) are well correlated.

[Effect of body fat percentage on estimated propofol concentrations at awakening from anesthesia using target controlled infusion].

BACKGROUND: Target controlled infusion (TCI) for propofol allows anesthesiologists to target constant blood concentrations of propofol. However, the pharmacokinetic parameters in TCI system do not take account of the patient's age, make up and gender. We evaluated the relationship between body fat percentage and the estimated effect site propofol concentrations at awakening. METHODS: Anesthesia was induced in 37 patients with fentanyl and propofol by TCI. Patients's percentage of fat was evaluated by measuring the thickness of the three parts of the skin fat with Skyndex (Caldwell Justiss, USA). After surgery and discontinuation of anesthesia, the estimated effect site propofol concentrations (EPEC) were determined when the patient could respond to verbal command. RESULTS: The EPECs at awakening were 1.5 +/- 0.2 micrograms.ml-1 in male and 1.5 +/- 0.3 micrograms.ml-1 in female. In male, the percentage of fat and body mass index (BMI) correlated significantly with EPEC (r = 0.79 and 0.49 respectively). In female, the percentage of fat and BMI did not correlate with EPEC. The estimated fentanyl effect site concentrations at awakening did not correlate with the EPEC. CONCLUSIONS: Male patients who have high percentage of fat have a tendency to delayed of awakening from propofol anesthesia. In female, however, no correlation was seen between percentage of fat and awakening time from propofol anesthesia. Measuring the percentage of fat might bring a new insight into pharmacokinetics of propofol.

[Spinal anesthesia with bupivacaine for a patient with a history of severe leg pain after intrathecal dibucaine].

An 87-year-old man was scheduled for the 11th transurethral bladder tumor resection (TURBT). He had a history of non-active syphilis for 21 years, diabetes mellitus for 7 years, and severe emphysema. Preoperative physical examination of the lower extremities, revealed loss of knee-jerk reflex, and loss of vibratory and proprioceptive perception. Four years previously, he underwent TURBT twice under spinal anesthesia with dibucaine, which caused severe leg pain during anesthesia. Therefore, subsequent TURBTs (eight times) were performed under general anesthesia with tracheal intubation, which frequently caused postoperative respiratory distress. Recently, bupivacaine, less neurotoxic than dibucaine, was on the market in Japan for use in spinal anesthesia. Therefore we planned spinal anesthesia using 0.5% bupivacaine, 2.0 ml. This time, he did not complain of leg pain during anesthesia, and postoperative conditions were satisfactory. We can conclude that bupivacaine is very useful for spinal anesthesia especially in patients with a history of leg pain by spinal anesthesia with dibucaine.

[Postoperative nausea and vomiting after open heart surgery].

We investigated the incidence of the postoperative nausea and vomiting (PONV) following cardiac surgery with cardiopulmonary bypass. We conducted a prospective study of 65 cases with direct interviews by anesthesiologists who are blind to this protocol every 6 hours during ICU stay. There were no differences in age, body mass index, dose of fentanyl, operating time, cardiopulmonary bypass time and ventilation time in ICU between PONV(+) and PONV(-). Incidence of PONV was 43%, but 70% of female patients complained of PONV. Prophylactic antiemetic strategy might be clinically relevant to female patients who are to undergo open heart surgery with cardiopulmonary bypass.