Renal involvement induced by human parvovirus B19 infection.

In an attempt to clarify the renal involvement induced by human parvovirus B19 (HPB19) infection, we investigated 6 adult patients with transient urinary abnormalities followed by erythema infectiosum. All patients had HPB19-specific IgM antibody and showed mild proteinuria of 0.2-1.2 g/day with or without microscopic hematuria. In 5 patients a decrease of complement was present, and in 2 the circulating immune complex levels were elevated. All patients showed mild or moderate endocapillary proliferation with leukocytic infiltrates in glomeruli and leukocytic infiltrates with edema around interlobular arteries and arterioles. Immunofluorescence microscopy revealed C3c deposits with immunoglobulins along the glomerular capillary walls and in the walls of small arteries and arterioles. Electron microscopic studies showed swelling of the endothelial cells and small electron-dense deposits in mesangium (in all 6 patients) and subendothelium (in 5 of 6 patients). However, HPB19 VP1 and VP2 capsid antigens were not demonstrated in the glomerulus or the vascular wall in any patient. These findings suggest that the renal lesions caused by an immune complex mediated phenomenon would be closely correlated with the HPB19 infection, although the precise mechanism is not entirely clear, and that in adults HPB19 should be thought of as a possible cause of acute postinfectious glomerulonephritis.

[A case of pneumonia, septic pulmonary embolisms with cavities, bilateral large lung abscesses, and multiple liver abscesses caused by Klebsiella pneumoniae].

A 64-year-old man suffering from diabetic hyperosmolar non-ketotic coma was admitted for acute lung abscess in the left apical lung field. Sputum culture and blood culture showed a heavy growth of Klebsiella pneumoniae (K. pneumoniae). He was suffering from sepsis, septic pulmonary embolisms with cavities, bilateral pulmonary consolidations, and multiple liver abscesses. Gradually, the bilateral lung consolidations resolved and areas of consolidation were noted to undergo extensive cavitation bilaterally. Cavitation and abscess formation are frequent complications of K. pneumoniae. Generally, large bilateral lung abscesses caused by K. pneumoniae have a poor prognosis. Cavity nodules are often present in septic pulmonary embolisms. We report a very rare case in a patient with three types of cavities with differing mechanisms. The first was an acute lung abscess, the second, septic pulmonary embolisms with cavities, and the third, large bilateral lung cavities noted in the course of resolving consolidations.

[A case of multiple emphysematous bullae treated with living-donor lung transplantation from identical twin brothers].

A 30-year-old man with multiple emphysematous bullae and bronchiectasis was admitted to Toyama Medical and Pharmaceutical University Hospital because of exertional dyspnea and fever. His chest radiograph and CT scan revealed multiple large bullae in the right lung and infiltrative shadows in the left middle lung field. Pseudomonas aeruginosa was isolated from his sputum culture. Although standard therapies including various antibiotics were administered, his respiratory condition was exacerbated, accompanied with the enlargement of bullae in the right lung and the consequent shift of the mediastinum to the left. The patient and his family proposed lung transplantation, and we concluded that lung transplantation would be an appropriate treatment for his disease. We transported the patient to Osaka University Hospital. Living-donor lung transplantation from the patient's identical twin brothers was successfully performed.

[Five patients with intrapulmonary lymph nodes indistinguishable from small peripheral carcinoma of the lung].

We encountered 5 patients with subpleural intrapulmonary lymph nodes. In all 5 patients, computed tomographic (CT) scans demonstrated subpleural small nodules in the middle or lower lung lobes. Because lung cancer could not be ruled out, biopsies by video-assisted thoracic surgery (VATS) were performed, yielding a diagnosis of intrapulmonary lymph nodes in all 5 cases. Two of the patients were women and nonsmokers. Sharply defined borders and subpleural locations were the characteristic CT findings for the intrapulmonary lymph nodes. However the borders of some of the nodules were irregular. Small peripheral lung cancer is also sometimes characterized by sharply defined borders and subpleural locations. For this reason, it is difficult to differentiate between intrapulmonary lymph nodes and small peripheral lung cancer on the basis of CT findings alone. VATS should be readily employed for diagnostic purposes in such cases.

Light chain deposition disease detected by antisera to a variable region of the kappa1 light chain subgroup.

A 59-year-old male started maintenance hemodialysis, and 80 months later died of congestive heart failure. Just before death he had no urine, and no monoclonal immunoglobulin could be demonstrated in the serum on immunoelectrophoresis. An autopsy showed deposition of periodic acid-Schiff-positive and Congo red-negative material in the interstitium and vessel walls of almost all organs and tissues. In the glomeruli there was a multifocal nodular accumulation of the material. Electron microscopy showed finely granular, not fibrillar deposits. In spite of these impressive lesions on light microscopy, the material was not stained with commercially available antisera to light chains. However, the material was positive for antisera to the variable region of the kappa1 light chain subgroup. This is the first case with light chain deposition disease that showed positive staining only with antisera to the variable region of the light chain.

Primary cardiac lymphoma diagnosed by percutaneous needle biopsy.

We diagnosed a case of primary cardiac lymphoma using transthoracic needle biopsy. A 70-year-old man was admitted because of dyspnea. Magnetic resonance imaging revealed a tumor mass in the right ventricular free wall. We performed ultrasound guided transthoracic needle biopsy using an 18-G needle, and diagnosed as malignant lymphoma by the biopsy specimen. This method may be useful for the diagnosis of cardiac lymphoma.

Methylprednisolone pulse therapy in two clinical types of crescentic glomerulonephritis.

To clarify the effectiveness of methylprednisolone pulse therapy on crescentic glomerulonephritis (CresGN), data of 46 patients was retrospectively studied. According to the slope of reciprocals of serum creatinine (s-Cr) the patients were divided into acute and insidious types, and each type was further divided into pulse (P) and conventional (C) therapy groups. In group C, s-Cr improved more frequently in the acute type (8/10) than in the insidious type (1/9, p<0.05), and the renal survival rate was somewhat higher in the former (p=0.09). In the acute type there was no difference in the improvement rate of s-Cr between the two therapy groups, whereas in the insidious type, the improvement rate was higher in group P (9/15) than in group C (1/9, p<0.05) and the renal survival rate was higher in the former (p<0.01). These results suggest that methylprednisolone pulse therapy may be highly effective for the insidious type of CresGN.

Necrotizing bronchial aspergillosis as a cause of hemoptysis in sarcoidosis.

The case history is presented of a patient with recurrent massive hemoptysis caused by necrotizing bronchial aspergillosis associated with sarcoidosis. The involved segments (right IX and X) were resected for treatment of the life-threatening hemoptysis. Histologic examination of the resected specimen confirmed the diagnosis. Necrotizing bronchial aspergillosis is a rare variant form of invasive pulmonary aspergillosis and has not been described previously as a cause of hemoptysis in sarcoidosis.

[Effects of methylprednisolone pulse therapy in the insidious type of crescentic glomerulonephritis].

In a attempt to clarify the effects of methylprednisolone pulse therapy on the insidious (subacute) type of crescentic glomerulonephritis with slow, but steady deterioration of renal function and poor response to treatment, we analyzed the clinical course of 24 patients (male:female = 15:9) with a mean age of 48.5 years. They fulfilled the following criteria: 1) crescents were observed in more than 50% of the glomeruli, 2) the increment of serum creatinine (Cr) could be determined sequentially on three or more occasions before treatment, and reciprocals of serum Cr declined with slopes of less than 1.0 x 10(-2) dl/mg/day, 3) corticosteroids and/or immunosuppressants were administered. The patients were divided into two groups: pulse therapy group (P) (15 patients), to which methylprednisolone 500 or 1,000 mg a day was administered intravenously for three consecutive days, and a conventional therapy group (C) (9 patients). There were no differences between groups P and C in clinical parameters, including sex, age, underlying diseases, urinary protein, blood pressure, serum Cr and slope of 1/Cr before treatment, and pathological findings, including percentages of glomeruli with crescents and degree of interstitial lesions. However, improvement of serum Cr, which was defined as a decline to the normal range or less than half of the pretreatment level, was observed in 9 (60%) in group P vs. only 1 (11%) in group C (p < 0.05). Re-biopsies were performed after treatment in 6 patients of group P with an improvement of serum Cr, and showed a decrease in the rate of crescent formation and almost complete loss of cellular crescents. At 1, 2 and 3 years follow-up, the renal survival rates were 86, 70 and 53%, respectively, in group P vs. 67, 14 and 14% respectively, in group C (p < 0.05). No serious side effects were observed in group P. These results suggest that methylprednisolone pulse therapy may be very effective for the insidious type of crescentic glomerulonephritis.

[Legionella pneumonia successfully treated despite late diagnosis].

Status asthmaticus developed in a 72-year-old man who was being treated with oral prednisolone for severe persistent asthma. The dosage of prednisolone was increased, and amikacin was injected to treat pneumonia that had developed in the right lung. Progressive pulmonary infiltrates, respiratory compromise, and hypoxemia developed, and the patient eventually required mechanical ventilation. Antibiotic treatment was changed to imipenem/cilastatin, piperacillin, gentamicin, clarithromycin, erythromycin, and minocycline. Liver injury developed. More than one month after the patient was admitted, Legionella pneumonia was diagnosed. Levofloxacin (400 mg/day) was then given orally, in combination with injected imipenem/cilastatin. Liver function did not deteriorate, and the pneumonia resolved. Most diagnoses of Legionnaires' disease are made retrospectively by examination of serum. In this case, antibiotics active against Legionella pneumophila had been used before the diagnosis was established, which probably contributed to the patient's recovery. When aminoglycosides or beta-lactam antibiotics are ineffective, administration of agents effective against Legionnaires' disease should be considered.

Acute eosinophilic pneumonia accompanied by Guillain-Barré syndrome.

A 74-year-old man presented with chest pain, dry cough, progressive respiratory distress and infiltrative lung shadow. Diagnosis of acute eosinophilic pneumonia was confirmed by histological examination as well as clinical features. On the 8th day post-admission, he developed progressive generalised muscle weakness that required mechanical ventilation. Clinical investigations revealed features concurring with the accepted diagnostic criteria for Guillain-Barré syndrome. Although precise aetiologies for the disorders suffered by this case were unknown, a common cause of allergic nature was speculated. This is the first report of acute eosinophilic pneumonia accompanied by Guillain-Barré syndrome.

Ethosuximide-induced lupus-like syndrome with renal involvement.

A 20-year-old man developed fever and urinary abnormalities with positive antinuclear antibody (ANA) two months after the start of ethosuximide. A renal biopsy showed mild mesangial cell proliferation and cellular crescents predominantly occupying a vascular pole in 7 out of 80 (8.8%) glomeruli. In the arteriole, mainly in close proximity to the glomerulus, proliferation of smooth muscle cells and luminal narrowing were observed. Discontinuation of ethosuximide led to the disappearance of fever, ANA and urinary abnormalities. These findings are strongly suggestive of a causal relationship between ethosuximide and a lupus-like syndrome with peculiar renal involvement.

[Abnormalities in pulmonary perfusion scans after transcatheter arterial embolization of the liver].

Thirteen patients with hepatocellular carcinoma who underwent transcatheter arterial embolization (TAE) were studied to evaluate the incidence of pulmonary embolism and methods for diagnosing this complication. Pulmonary perfusion scans and changes in indexes of coagulation and of fibrinolysis, and in the partial pressure of oxygen in arterial blood were evaluated as possible signs of pulmonary embolism complicating TAE. In 3 out of 13 patients (23%), perfusion lung scans showed perfusion defects. These 3 patients were asymptomatic and their perfusion defects had disappeared by 4 weeks later. TAE was followed by significant decreases in platelet counts (p < 0.01) and in serotonin levels (p < 0.05); and by increases in A-aDO2 (p < 0.01), in levels of fibrinogen in plasma (p < 0.01), and in levels of thrombin-antithrombin III complex (TAT) (p < 0.05), with no significant increase in levels of D-dimer in plasma. Similar hematologic changes were observed in patients without perfusion defects after TAE. In 3 patients with perfusion defects, plasma levels of TAT before TAE were significantly higher than the levels in patients without perfusion defects (p < 0.01). Perfusion defects that occur after TAE may be caused by pulmonary thromboemboli, by pulmonary fat emboli, and by microatelectasis or discoid atelectasis, and the most common cause is probably pulmonary thromboemboli. We conclude that the risk of pulmonary embolism complicating TAE is higher in patients with hepatocellular carcinoma who have high levels of TAT in plasma.

Interventricular septal dissection in a patient with an old myocardial infarction.

We observed an unusual case of interventricular septal wall dissection in a patient with a prior myocardial infarction. Echocardiography, magnetic resonance imaging, and left ventriculography revealed separation of the right-side and left-side walls of the interventricular septum with an accessory chamber between the two walls. Morphologic findings were consistent with interventricular septal dissection.