Unilateral adrenal hematoma with associated giant mass: a report of two cases.

Background: Adrenal hematoma is a rare yet potentially life-threatening event that occurs both in traumatic conditions and in a variety of nontraumatic conditions. In the present study, we report the two cases with idiopathic unilateral adrenal hematoma. Case presentation: Case 1 involved a 72-year-old man who was complaining of upper abdominal pain. Abdominal computed tomography (CT) and magnetic resonance imaging (MRI) demonstrated a giant mixed density tumor in the right retroperitoneal space. To remove the tumor, we carried out an adrenalectomy on the right adrenal gland, resecting a specimen measuring 15 × 13.5 cm. The histopathological findings of the specimen revealed a hematoma with normal adrenal tissue. Case 2 involved a 53-year-old woman who complained of an uncomfortable feeling in her left upper abdomen. A retroperitoneal tumor had formed a multicystic lesion and resected because the left renal vein had become compressed. The resected specimen was 10.5 × 10 cm in size and revealed an adrenal hematoma. In the absence of any obvious etiology, the diagnoses in both cases were idiopathic adrenal hematoma. Conclusion: An accurate diagnosis of idiopathic adrenal hematoma is quite difficult to make prior to surgery. Some imaging modalities are useful in generating a differential diagnosis.

Adiponectin deficiency promotes the production of inflammatory mediators while severely exacerbating hepatic injury in mice with polymicrobial sepsis.

BACKGROUND: Adiponectin (APN), which is an adipose tissue-derived hormone, is known as an anti-inflammatory cytokine. The effects of APN on the production of inflammatory mediators and hepatic injury during polymicrobial sepsis were evaluated using APN-knockout (KO) mice that had undergone a cecal ligation and puncture (CLP) and rosiglitazone, a selective peroxisome proliferator-activated receptor gamma (PPARgamma) agonist, which increases the plasma APN concentration. MATERIALS AND METHODS: Wild type (WT) and APN-KO mice were underwent CLP. The plasma and hepatic levels of inflammatory mediators, including tumor necrosis factor-alpha (TNF-alpha), interleukin-6 (IL-6), and monocyte chemoattractant protein-1 (MCP-1), were measured before, at 24, and 48 h after CLP. A histological analysis of the liver and the plasma alanine aminotransferase (ALT) levels were examined to evaluate hepatic injury. The plasma levels of inflammatory mediators after CLP with pretreatment of rosiglitazone were compared with those without rosiglitazone. RESULTS: APN deficiency resulted in significant increases in the plasma levels of TNF-alpha, IL-6, and MCP-1 at 24 h after CLP. Hepatic MCP-1 and plasma AST levels in APN-KO mice were significantly higher than those in WT mice at 48 h after CLP. A steatosis change and MCP-1 expressions in hepatocytes were induced in APN-KO mice during sepsis. The administration of rosiglitazone significantly lowered the plasma levels of inflammatory mediators, including TNF-alpha, IL-6, and MCP-1, in WT mice but not in APN-KO mice during sepsis. CONCLUSION: These results suggest that an APN deficiency induces an excessive systemic inflammatory status and exacerbates hepatic injury during polymicrobial sepsis.

Development of Lobular Panniculitis Long After Completing the Personalized Peptide Vaccine Therapy.

BACKGROUND Personalized peptide vaccine therapy is regarded as a well-tolerated, safe and effective immunotherapy for patients with advanced cancers. Herein we report an exceptional case of a patient with advanced pancreatic cancer who developed delayed lobular panniculitis at sites corresponding to vaccine injections. CASE REPORT A 64-year-old Japanese female visited our clinic due to thirst and polydipsia; she was diagnosed as having type 2 diabetes. Simultaneously, she was diagnosed as having advanced pancreatic cancer; and a distal pancreatectomy and splenectomy were performed. Afterwards, she received adjuvant chemotherapy with titanium silicate-1 and personalized peptide vaccination using Montanide® ISA-51 by a subcutaneous injection to her abdomen over a total of 30 times. Thirteen months after the vaccine therapy had come to an end, lobular panniculitis appeared at the vaccination sites. At this point, corticosteroid was administered, resulting in significant improvement in the condition of the subcutaneous nodules. CONCLUSIONS This case report highlights the importance of careful patient explanation before initiation of cancer vaccine therapy about the possibilities of lobular panniculitis as an adverse event. It also highlights that it is important that physicians have a greater awareness of the possibility of panniculitis in patients with concerns regarding subcutaneous indurations even long after the end of peptide vaccine therapy.

A case report of pulmonary-renal syndrome treated with continuous hemodiafiltration and hemodialysis.

This case describes a 40-year-old man complaining of general malaise, dyspnea with hemoptysis and anuria. Laboratory data indicated renal failure and the presence of systemic inflammation. His chest radiograph and computed tomography showed bilateral diffuse interstitial alveolar infiltration. These findings indicated acute deterioration of chronic renal dysfunction complicated by interstitial pneumonitis. He initially received daily conventional hemodialysis (HD), an antibiotic and oxygen therapy. However, his renal and pulmonary function continued to deteriorate. Antineutrophil cytoplasm antibodies against myeloperoxidase (MPO-ANCA) and antibodies against proteinase 3 (PR3-ANCA) were negative. We suspected that his pulmonary-renal syndrome was caused by ANCA-negative vasculitis. We applied mechanical ventilation, pulsed methylprednisolone therapy and continuous hemodiafiltration (CHDF) combined with HD. PaO(2)/FiO(2) ratio and mean pulmonary arterial pressure gradually improved after initiation of CHDF. He was finally separated from mechanical ventilation after 44 days in the hospital. He is currently alive with the support of conventional HD.

Plasma Adiponectin Levels in Acute Liver Failure Patients Treated with Plasma Filtration with Dialysis and Plasma Exchange.

Plasma filtration with dialysis (PDF) is a blood purification therapy in which simple plasma exchange (PE) is performed using a selective membrane plasma separator while the dialysate flows outside of the hollow fibers. Improvement of hypoadiponectinemia is considered to be a useful therapeutic approach for ameliorating fatal conditions including cardio-metabolic and infectious disease. We investigated the effects of PDF in comparison to PE in terms of plasma adiponectin (APN) changes in patients with acute liver failure. Seventeen patients with liver failure were studied; PDF was performed 55 times and PE 14 times. Plasma APN levels increased significantly after PDF, while decreasing significantly after PE. PDF appears to be among the most useful blood purification therapies in acute liver failure cases in terms of increasing APN levels.

Association between reduction of plasma adiponectin levels and risk of bacterial infection after gastric cancer surgery.

BACKGROUND AND PURPOSE: Infections are important causes of postoperative morbidity after gastric surgery; currently, no factors have been identified that can predict postoperative infection. Adiponectin (ADN) mediates energy metabolism and functions as an immunomodulator. Perioperative ADN levels and perioperative immune functioning could be mutually related. Here we evaluated a potential biological marker to reliably predict the incidence of postoperative infections to prevent such comorbidities. METHODS: We analyzed 150 consecutive patients who underwent elective gastric cancer surgery at the Shiga University of Medical Science Hospital (Shiga, Japan) from 1997 to 2009; of these, most surgeries (n = 100) were performed 2008 onwards. The patient characteristics and surgery-related factors between two groups (with and without infection) were compared by the paired t-test and χ(2) test, including preoperative ADN levels, postoperative day 1 ADN levels, and ADN ratio (postoperative ADN levels/preoperative ADN levels) as baseline factors. Logistic regression analysis was performed to access the independent association between ADN ratio and postoperative infection. Finally, receiver operating curves (ROCs) were constructed to examine its clinical utility. RESULTS: Sixty patients (40%) experienced postoperative infections. The baseline values of age, American Society of Anesthesiologists physical status, total operating time, blood loss, surgical procedure, C-reactive protein (CRP) levels, preoperative ADN levels, and ADN ratio were significantly different between groups. Logistic regression analysis using these factors indicated that type 2 diabetes mellitus (T2DM) and ADN ratio were significantly independent variables (*p<0.05, ** p<0.01, respectively). ROC analysis revealed that the useful cutoff values (sensitivity/specificity) for preoperative ADN levels, ADN ratio, blood loss, operating time, and CRP levels were 8.81(0.567/0.568), 0.76 (0.767/0.761), 405 g (0.717/0.693), 342 min (0.617/0.614), and 8.94 mg/dl (0.583/0.591), respectively. CONCLUSION: T2DM and ADN ratio were independent predictors of postoperative infection and ADN ratio was the most useful predictor for postoperative infection.

Adiponectin deficiency is associated with severe polymicrobial sepsis, high inflammatory cytokine levels, and high mortality.

BACKGROUND: Adiponectin, a key substance in metabolic syndrome, is known to have anti-inflammatory properties. The relationship between adiponectin and sepsis in vivo is unclear. In this study, the possible involvement of adiponectin in polymicrobial sepsis was investigated using adiponectin-knockout (APN-KO) mice that underwent cecal ligation and puncture (CLP) and received the peroxisome proliferator-activated receptor gamma (PPAR-gamma) that increases the plasma adiponectin concentration. METHODS: APN-KO and wild-type (WT) mice underwent either CLP or a sham operation. The plasma adiponectin, endotoxin, tumor necrosis factor-alpha (TNF-alpha), and interleukin-6 (IL-6) levels were determined before and at 2, 4, 6, 8, 12, 16, and 24 hours after the procedures, and the survival rates were compared. Mice were injected with rosiglitazone, a selective PPAR-gamma agonist, and compared survival rates after CLP with those without rosiglitazone. RESULTS: After CLP, APN-KO mice had a significantly higher mortality than WT mice. The plasma endotoxin, TNF-alpha, and IL-6 levels in APN-KO mice were significantly higher than those in WT mice 24 hours after CLP. Within 4 hours after CLP, the plasma adiponectin level in WT mice decreased to half of the initial levels. Pre-CLP treatment with PPAR-gamma was shown to increase the plasma adiponectin level and to improve significantly mortality of WT mice during sepsis; mortality among APN-KO mice did not improve. CONCLUSION: These results suggest that adiponectin deficiency may cause the high mortality and the high inflammatory cytokine levels in mice with polymicrobial sepsis.

Edaravone improves the survival of rats subjected to hemorrhagic shock without resuscitation.

Our aim in this study was to find out whether edaravone (3-methyl-1-phenyl-pyrazolin-5-one, MCI-186), a novel free radical scavenger, improved the survival rate in a rat hemorrhagic shock (HS) model. Fifty male Sprague-Dawley rats were divided randomly into an edaravone group and a saline group. Both groups were subjected to HS by inducing a mean arterial pressure of 30 mmHg for 60 min without resuscitation. The edaravone group was divided into four subgroups based on when edaravone was given: 0, 15, 30, or 60 min after HS. The saline group was given saline immediately after HS. We evaluated the 24-h survival rate in each group. The survival rate of the edaravone subgroup given edaravone immediately after HS was significantly better than that of the saline group. Edaravone improved the survival rate in a rat HS without resuscitation model. Edaravone was most effective when given immediately after HS.

Relations among circulating monocytes, dendritic cells, and bacterial translocation in patients with intestinal obstruction.

BACKGROUND: Little evidence is available regarding the relations among circulating monocytes, dendritic cells (DCs), and bacterial translocation (BT) in patients with intestinal obstruction. METHODS: We investigated alterations in DCs in mesenteric lymph nodes (MLNs), circulating immune cells (white blood cell, lymphocyte, and monocyte counts), and BT to MLNs in 21 patients undergoing abdominal surgery because of intestinal obstruction. We also examined whether BT correlated with the development of perioperative systemic inflammatory response syndrome (SIRS) and postoperative septic complications. RESULTS: BT subsequent to intestinal obstruction was observed in 7 (33%) patients. Preoperative circulating immune cell counts were significantly lower in BT-positive patients than those in BT-negative patients. The presence of preoperative SIRS was also significantly related to BT-positive status. A preoperative monocyte count <290/mm(3) was the best predictive factor for BT in MLNs during intestinal obstruction: sensitivity 85.7%; specificity 92.3%; positive and negative predictive values 85.7% and 92.9%, respectively. The area under the receiver operating characteristic curve was 0.944. The expression of S-100 protein-positive DCs in MLNs significantly increased in BT-positive patients. CONCLUSIONS: A significant inverse correlation was observed between the circulating monocyte count and the ratio of DCs among all cells in MLNs (r(2)= 0.259). Postoperative septic complications were 3.3 times more common in BT-positive patients than in BT-negative patients. A significant increase in the expression of DCs in MLNs was observed in patients with BT subsequent to intestinal obstruction. Our findings suggested that a low monocyte count (<290 /mm(3)) and the presence of preoperative SIRS might be useful factors for predicting BT in patients with intestinal obstruction.