Intermittent gait disturbance in idiopathic normal pressure hydrocephalus.

OBJECTIVES: We identified intermittent gait disturbance (IGD) observed in the mild stage of idiopathic normal pressure hydrocephalus (iNPH). The first purpose of this study was to clarify the temporal gait profile of IGD during long-distance gait. The second purpose was to confirm the difference in treatment effect after cerebrospinal fluid (CSF) shunting in patients with and without IGD. MATERIALS AND METHODS: Fourteen consecutive iNPH patients with mild gait disturbance with a timed up-and-go (TUG) of <20 seconds were prospectively enrolled in the study. All patients were asked "Do you experience gait difficulty after over five minutes of walking?" Seven "yes" patients formed the IGD group, and seven "no" patients formed the persistent gait disturbance (PGD) group. One day before and 7 days after CSF shunting, gait function was evaluated by the 6-minute walk test (6MWT) and TUG. RESULTS: Preoperatively, all patients in the IGD group demonstrated features of IGD during the 6MWT, characterized by a progressive pattern of decreased gait speed and step length with increased cadence and absence of leg pain. Post-operatively, these features of IGD improved in all patients. In the PGD group, preoperative walking did not significantly worsen during the 6MWT and did not significantly change 7 days after treatment. Improvement of gait symptoms 1 week after CSF shunting could be detected with 6MWT instead of TUG. CONCLUSIONS: Intermittent gait disturbance is not a rare symptom in mild stage of iNPH and may serve as an important clinical diagnostic marker for identifying mild iNPH patients.

Terminal pulmonary infections in patients with lung cancer.

To determine the factors that predispose the patient with lung cancer to develop terminal pulmonary infections, we reviewed the case records and autopsy data of 304 patients who died of lung cancer in the Kyushu University Hospital between 1976 and 1990. The incidence of mycobacterial infection was significantly higher among those treated with antineoplastic therapy and corticosteroids (group 3) than in those who received antineoplastic therapy alone (group 2). The incidence of nonbacterial infection did not differ significantly between the two groups. In some group 3 patients, the administration of corticosteroids for relatively short periods (less than one month) led to fatal mycobacterial infection. Among those patients with lymphocytopenia, the incidence of fatal mycobacterial infection was significantly higher in group 3 than in group 2, whereas the incidence of fatal nonbacterial infection was not. In group 3, the incidence of fatal mycobacterial and nonbacterial infections did not differ significantly among those with and without lymphocytopenia. Thus, in patients with lung cancer who were receiving antineoplastic treatment, corticosteroids were more closely associated with the development and exacerbation of mycobacterial infection than was lymphocytopenia. The influence of corticosteroids on the development of nonbacterial infection was not more marked than that of lymphocytopenia. The incidence of common bacterial infections was no higher among those patients who received no antineoplastic treatment or corticosteroid (group 1), group 2, and group 3. Therefore, the local and systemic effects of the lung cancer itself are likely more important in predisposing the patient to bacterial infections than are either antineoplastic agents or corticosteroids.

Rifampicin resistance and mutation of the rpoB gene in Mycobacterium tuberculosis.

Using 39 clinical isolates of Mycobacterium strains with a broad range of susceptibility to rifampicin, we examined the relationship between the degree of resistance to rifampicin and mutational sites of the rpoB gene. All rifampicin-resistant strains had missense mutations. Twenty strains (95%) had a mutation in the cluster I region, which has also been reported in Escherichia coli [Jin and Gross (1988) J. Mol. Biol. 202, 45-58], and the remaining one strain had a mutation at codon 381 [Ala-->Val] in the N-terminal region, which has not been reported in E. coli. Among 18 rifampicin-susceptible strains, two had a mutation in the cluster I region and the other three strains had a mutation in the cluster III region. The mutations at codons 513 (5%), 526 (33%) or 531 (43%) in the cluster I region led to high level resistance to rifampicin (50 micrograms ml-1 < or = MIC). The mutations at the other sites, in the cluster III region (codons 679 or 687) and even in the cluster I region (codon 514, 521, or 533), showed low level (MIC = 12.5 micrograms ml-1) or no (MIC < 0.39 microgram ml-1) resistance to rifampicin. These results suggest that mutations in the rpoB gene are, mostly, but not necessarily, associated with rifampicin resistance of M. tuberculosis, and the sites of mutations on the rpoB gene will affect the level of resistance to rifampicin.

Increased plasma adenosine deaminase activity in the early phase of Legionella pneumophila infection in guinea pigs.

We measured adenosine deaminase (ADA) activity in a guinea pig model of Legionella pneumophila infection. Female Hartley guinea pigs were inoculated intraperitoneally with one-quarter of the LD50 dose of L. pneumophila Philadelphia-1 strain. Control groups were inoculated with clinical isolates of Staphylococcus aureus, Streptococcus pneumoniae, Haemophilus influenzae or Klebsiella pneumoniae. Each group consisted of 5 animals. ADA activity in plasma was assayed calorimetrically before and at various intervals after infection by measuring the amount of ammonia produced after adenosine was added to plasma samples. ADA activity before inoculation was 25.6 +/- 6.0 IU/1, it reached 174.4 +/- 60.0 IU/1 on day 3 after inoculation of L. pneumophila. ADA activity returned to normal levels on day 14. ADA activity did not increase significantly in guinea pigs infected with the other types of bacteria. These findings suggest that measurement of plasma ADA activity may be useful for the diagnosis of Legionella infection.

Germinoma causing wallerian degeneration. Case report and review of the literature.

Germinomas occurring in the thalamus and basal ganglia sometimes cause atrophy of the cerebral hemisphere on the affected side. The authors present the case of a 12-year-old girl with a germinoma that developed in the basal frontal lobe and cerebral basal ganglia. Magnetic resonance imaging showed atrophy not only of the cerebrum but also of the brainstem. A T2-weighted image revealed an area of high intensity that proved to be wallerian degeneration extending from the corona radiata and internal capsule to the brainstem. The authors suggest that this pathological change may be involved in the development of the symptoms and hemiatrophy associated with germinomas in this region of the brain.

Lipoma in the quadrigeminal cistern--case report.

A 65-year-old male presented with a rare lipoma in the quadrigeminal cistern manifesting as left abducens nerve paresis which was effectively treated by total extirpation. The usual neurological symptoms of lipoma in the quadrigeminal cistern are intracranial hypertension and hydrocephalus which can be successfully treated by shunt operation. Direct surgery is indicated when the symptoms are ascribed to localized symptoms, but tumor removal should be partial if the superior cerebellar arteries are involved.

[A comparative study of multimodality evoked potentials and computed tomography in head injuries].

Multimodality evoked potentials (EPs) or three types of EPs--auditory brainstem response (ABR), somatosensory evoked potential (SEP), and visual evoked potential (VEP)--were recorded in 51 cases of traumatic intracranial hemorrhage within 3 days after injury. In order to assess these EPs, five EP grades were constructed, from normal, Grade I, to highly abnormal, Grade V. Furthermore, an EP pattern classification was devised to integrate the respective EP grades. Namely, PA, consisting of all three EPs within Grades I-III; PB, composed of one type of EP or both ABR and VEP at Grades IV and V; PC, consisting of both SEP and VEP at Grades IV and V; PD, comprising both ABR and SEP at Grades IV and V; and PE, covering all three EPs at Grades IV and V. PA signifies "no severe damage," PB, "localized damage," PC, "severe cerebral damage," PD, "severe brainstem damage," and PE, "severe diffuse damage." The results when compared with computed tomography (CT) findings were as follows: 1) The size of hematoma correlated with the SEP grade in 16 cases of acute epidural hematoma; a hematoma diameter of 17.5 mm was the threshold value at which SEP abnormalities developed. Eleven patients who underwent surgical removal of the hematoma showed "no severe damage," and the outcome was good. 2) In 13 cases of acute subdural hematoma, six cases revealed "severe cerebral damage" or "severe diffuse damage." In such cases, the degree of damage was not related to the hematoma size, and the outcome was very poor. 3) In 13 cases of a solitary contusional hemorrhage, only one case revealed "severe diffuse damage" and subsequently died.(ABSTRACT TRUNCATED AT 250 WORDS)

Spontaneous thoracic spinal cord herniation--case report.

A 54-year-old female presented with spontaneous thoracic spinal cord herniation manifesting as chronic progressive motor weakness in both legs. Spastic paraparesis (4/5) and pathological reflexes such as ankle clonus were noted. She also had mild bladder dysfunction but no bowel dysfunction. She had no sensory disturbance, including tactile and pinprick sense. Magnetic resonance (MR) imaging revealed that the atrophic spinal cord was displaced into the ventral extradural space at the T4-5 intervertebral level with markedly dilated dorsal subarachnoid space. Computed tomography obtained after myelography showed no evidence of intradural spinal arachnoid cyst. She underwent surgical repair of the spinal cord herniation via laminectomy, and spinal cord herniation through the ventral dural defect was confirmed. Postoperative MR imaging revealed improvement of the spinal cord herniation, but her symptoms were not improved. Spontaneous spinal cord herniation is a rare cause of chronic myelopathy, occurring in the upper and mid-thoracic levels, and the spinal cord is usually herniated into the ventral extradural space. Early differential diagnosis from intradural spinal arachnoid cysts is important for a satisfactory outcome.

Trigeminal neuralgia associated with venous angioma--case report.

A 35-year-old male presented with trigeminal neuralgia associated with venous angioma at the root entry zone. Magnetic resonance imaging and angiography demonstrated a venous angioma with a dilated petrosal draining vein, and displacement of the anterior inferior cerebellar artery (AICA). The AICA and dilated petrosal vein were both decompressed, resulting in complete relief from symptoms of trigeminal neuralgia for 30 months. Microvascular decompression rather than resection of venous angioma is recommended for treatment of such cases. The possibility of a venous anomaly should be considered in younger patients with trigeminal neuralgia.

Strategies to improve the outcome of carotid endarterectomy.

The outcomes of carotid endarterectomy (CEA) including long-term results in 121 patients (126 procedures) were retrospectively analyzed to identify the causes of operative morbidity. The angiographic internal carotid artery (ICA) stenosis was severe (> 70%) in 62 patients and moderate (50-70%) with ulceration in 64. The arterial wall was sutured primarily in 91 patients and with patch graft in 35. The outcomes 3 months after operation were good recovery in 86 patients, moderately disabled in 20, severely disabled in 11, and death in four. Three patients suffered operative morbidity (2.5%). During follow-up, three patients (2.6%) suffered transient ischemic attack on the operative side due to middle cerebral artery stenosis (50%) or ICA occlusion at the origin, and recurrent stenosis (40%) of the common carotid artery and ICA (1 each). In the latter two cases, the artery was primarily sutured. Improved therapeutic results require use of patch vein graft for the arterial wall suture, checking of the CEA patency, and prevention of intracranial ischemic events and hemorrhage due to associated lesions.

Cine-magnetic resonance imaging evaluation of communication between middle cranial fossa arachnoid cysts and cisterns.

Cine-magnetic resonance (MR) imaging examinations were performed in 10 patients with middle cranial fossa arachnoid cysts to evaluate communication between the cysts and the normal cerebrospinal fluid (CSF) space. Eight of 10 patients were evaluated by time of flight cine-MR imaging, and two by phase contrast cine-MR imaging. Two patients underwent membranectomy of the cysts, and were evaluated both pre- and postoperatively. Computed tomography cisternography was used to confirm communication between the cysts and the surrounding cisterns. Pulsatile fluid motion within the cysts was present in all patients. However, marked fluid motion and jet flow between the cysts and the surrounding cisterns were only observed in communicating cysts. In the two patients who underwent membranectomy, postoperative examination found greater fluid motion and jet flow not previously present. Cine-MR imaging demonstration of marked pulsatile fluid motion accompanied by jet flow suggests that a cyst communicates with the normal CSF space.

Eosinophilic granuloma associated with intratumoral hemorrhage--case report.

A 2-year-old boy presented with a rapidly growing soft scalp mass in the left parietal region. Surgical exploration and histological examination demonstrated an eosinophilic granuloma associated with intratumoral hemorrhage. Eosinophilic granuloma should also be considered when a scalp mass lesion exhibits rapid growth.

Cortical and subcortical cavernous angioma: a comparison of patients with and without hemorrhage as the initial symptom.

Cavernous angioma is a benign vascular hamartoma with an obscure etiology. Clinical, radiological, and histological features of 24 cases of cortical and subcortical cavernous angiomas were analyzed to investigate the etiology. The lesions were classified as hemorrhaging (8 cases) or non-hemorrhaging (16 cases) according to the initial symptom. Age, sex, location, calcification and postcontrast enhancement by computed tomography (CT), tumor staining by angiography, and calcification and hemosiderin by histological examination were analyzed. Multivariate analysis showed that calcification by CT and histological examination correlated with non-hemorrhaging cases. Histological examination showed that calcification occurred inside and outside the blood vessels, within the vessel walls and in the adjacent brain tissue. Hemosiderin was also seen in most cases. These findings suggest that cavernous angiomas without hemorrhage have a poor circulation, resulting in minor recurrent bleeding and thrombosis, as well as calcification.

In vitro effects of monobactams on Legionella pneumophila.

The effects of azthreonam and carumonam against Legionella pneumophila Philadelphia-1 strain in liquid medium and in phagocytic cells were examined. The minimum inhibitory concentration (MIC) of azthreonam for the bacteria was 12.5 micrograms/ml at a concentration of 1.4 X 10(4) colony forming units (CFU) and 25 micrograms/ml at a concentration of 1.4 X 10(5) CFU. MIC of carumonam was 25 micrograms/ml in both concentrations of the bacterial suspension. In guinea pig macrophages, both azthreonam and carumonam at a concentration of 100 micrograms/ml did not inhibit the multiplication of the bacteria.

Intracellular multiplication of Legionella pneumophila in Tetrahymena thermophila.

It has been shown that Legionella pneumophila proliferates intracellularly in more than ten species of protozoa, but the fate of the bacteria in Tetrahymena thermophila has not been reported. We investigated the multiplication of L. pneumophila Philadelphia-1 strain in micronucleated T. thermophila, and the effects of temperature and numbers of the bacteria ingested by the protozoa after in vitro feeding were studied. T. thermophila preyed actively upon the bacteria. After being ingested, the fate of the bacteria was affected by both temperature and the number of bacteria ingested. When the number of ingested bacteria was 30 per protozoon, the bacteria proliferated intracellularly at 35 degrees C. The bacteria, however, could not proliferate at 28 degrees C or 32 degrees C though they survived in the protozoa. When the ingested bacteria was 10 per protozoon, the bacteria were killed in the protozoa at all of the temperatures tested. Electron microscopic examination revealed that the protozoa ingesting the bacteria remarkably swelled and that protozoan food vacuoles which contained L. pneumophila were studded with ribosomes.

[An autopsy case of lymphoid interstitial pneumonia with monoclonal gammopathy].

An autopsy case of a 75-year-old female with lymphoid interstitial pneumonia with monoclonal gammopathy of IgA kappa type is reported. The patient was admitted to UOEH Hospital suffering from a cough, sputum and fever. After examining a specimen of transbronchial lung biopsy and chest X ray films, lymphoid interstitial pneumonia was suspected. Serum immunological examination showed monoclonal IgA kappa type hypergammaglobulinemia. Marked clinical and radiological improvement was attained after prednisolone administration. After 16 months, however, the patient deteriorated and expired on January 21, 1986. On postmortem examination, a number of plasma cells as well as lymphoid cells were seen to have infiltrated in the thickened interalveolar septa and the parenchyme of the lymph nodes throughout the whole body. The architecture of lymph nodes remained preserved, while the cortex as well as the medulla was almost completely replaced by plasma cells and lymphoplasmacytoid cells. Immunohistochemical examination demonstrated the presence of IgA kappa in the plasma cells and some of the lymphoplasmacytoid cells in both lymph nodes and lungs. These findings suggest that the proliferating plasma cells and lymphoplasmacytoid cells were in neoplastic or preneoplastic states and support the hypothesis that lymphoid interstitial pneumonia may be an expression of the systemic lymphoproliferative disorders in the lung.

[Isolation of Legionella pneumophila from the UOEH cooling tower].

Twelve samples of water taken from the cooling tower of UOEH were examined for the presence of microorganisms belonging to the genus Legionella by using a new selective medium, Wadowsky-Yee-Okuda (WYO) medium. Three samples contained this organism and they were identified as Legionella pneumophila from their biochemical properties. Among the three contaminated samples, two yielded L. pneumophila serogroup 1 and 3, and the other contained only L. pneumophila serogroup 1. One of the samples of the contaminated cooling tower water was treated with sodium hypochlorite as a disinfectant, indicating that this agent is probably not effective in eliminating L. pneumophila from cooling tower water at that concentration. An effective method of disinfection for Legionella spp. in the cooling tower must be developed to prevent infection in the hospital.

Hypoglycemia associated with localized fibrous mesothelioma of the pleura.

Hypoglycemia is known to be a rare consequence of non-islet cell tumors. A patient having severe, episodic hypoglycemia was found to have a large mass occupying the right hemithorax. The hypoglycemia resolved immediately after surgical removal of the tumor. Histologic examination of the tumor revealed localized fibrous mesothelioma.

[The analysis of the result of the medical examination of inhabitants in the Honjoh area--the relationship between the abnormality in the electrocardiogram and blood pressure, age].

Blood pressure and electrocardiographic findings obtained from the medical screening of citizen (total 834) in Honjyo area, which was done in University of Occupational and Environmental Health Hospital from 1979 to 1983, were analysed. The findings of electrocardiograms (ECG) were classified according to Minnesota code. In this study, the prevalence of Hypertension, classified by the criteria of WHO, showed 12.2% in total, which was lesser than that of Japanese (23.1%). On the electrocardiographic findings, left ventricular hypertrophy and myocardial abnormalities in hypertensive group were significantly higher when compared to those of normotensive group. The ratio of abnormal ECG group was slightly higher than that of Japanese. Especially, the prevalences of arrhythmia and ST elevation were significantly higher than those of Japanese. And there were significant correlations between LVH and blood pressure, and between the abnormalities of conduction system and age. However, it is very difficult to conclude whether these findings are characteristic feature in Honjyo area or not. In order to clarify the characteristic features of cardiovascular systemic abnormalities in Honjyo area, the analysis of more cases would be needed.

[Clinical efficacy of imipenem/cilastatin sodium for respiratory infections in patients with lung cancer].

Imipenem/cilastatin sodium (IPM/CS) was administered to 102 patients with respiratory tract infections and lung cancer. Patients with other serious diseases were excluded and a total of 73 patients were enrolled. They were divided into 12 patients who underwent surgery (operated group) and 61 who did not (non-operated group); the latter group included 28 patients treated with anticancer agents or radiation therapy (treated group) and 33 untreated patients (untreated group). IPM/CS was effective in 75% of the patients, both with and without surgery. The drug was effective in 81% of the treated group, although many of the patients had Stage III or more advanced cancer, as well as bronchial occlusion. IPM/CS was also effective in 69% of the untreated group, although many of the patients have serious infections and a PS (Performance Status) of 3 or greater. Thus, IPM/CS treatment achieved good results. Bacteriological studies showed that 3 out of 4 strains in the operated group and 16 out of 18 in the non-operated group were eliminated. Safety was evaluated in all patients. Two patients (2%) experienced side effects and two others (2%) showed abnormal clinical findings, but the symptoms were mild and resolved after discontinuation or completion of therapy. In conclusion, IPM/CS was very effective for treating respiratory infections in patients with lung cancer.