Renal vein thrombosis associated with oral contraception and smoking: a case report from Japan, with literature review.

Renal vein thrombosis, one of the common thrombotic complications of nephrotic syndrome or renal cell carcinoma, is reportedly a rare complication of hormonal contraception. Solitary renal vein thrombosis in the Japanese population is thought to be very rare because the incidence of venous thromboembolism is comparatively very low in Asian populations. We report a 38-year-old Japanese female with left renal vein thrombosis associated with oral contraception and concurrent smoking as the first Japanese case of solitary renal vein thrombosis associated with oral contraceptives, with a review of the literature. Seven cases were previously reported. The results revealed that all patients complained of acute onset of pain around the involved kidney without urinary symptoms or fever, and were effectively treated with anticoagulants. Other remarkable facts include that nausea and vomiting were frequently seen, and that the renal outcome was benign, despite various initial urine abnormalities. This report may alert clinicians to the importance of these risk factors as an etiology of renal vein thrombosis even in Asian populations. Clinicians should regard renal vein thrombosis as one of the differential diagnoses for acute flank pain in patients using oral contraceptives. A detailed history taking that reveals oral contraception, smoking, and other thrombophilic predispositions as well as timely computed tomographic scans would be the keys to diagnosis. Smoking cessation should be strongly recommended to oral contraceptive users, especially women over 35 years of age, regardless of dosage.

Meningococcemia due to the 2000 Hajj-associated outbreak strain (Serogroup W-135 ST-11) with immunoreactive complications.

We present the first reported case of systemic infection with Neisseria meningitidis serogroup W-135 sequence type (ST)-11 in Japan. A 44-year-old woman presented with high fever, sore throat, and fatigue and was diagnosed with N. meningitidis bacteremia. The causative strain was identified as serogroup W-135 ST-11 by polymerase chain reaction and multilocus sequence typing. Approximately 1 month after treatment, she developed high fever, dyspnea, chest pain, and shoulder pain due to pericarditis, polyarthritis, and tenosynovitis, which are all relatively common immunoreactive complications of W-135 ST-11 meningococcal infections. This causative strain was the same as that responsible for an outbreak of meningitis among Hajj pilgrims in 2000. The strain is now found worldwide because it can attain a high carriage rate and has a long duration of carriage. We suspect that our patient's infection was acquired from an imported chronic carrier.

Complete atrioventricular block associated with not apical but midventricular ballooning.

An 86-year-old woman was admitted to hospital with a head injury secondary to an episode of syncope associated with incontinence. Electrocardiography showed complete atrioventricular block, giant negative T waves in the precordial leads, and QT interval prolongation. Emergency coronary angiography showed no significant coronary stenosis, while left ventriculography demonstrated midventricular ballooning. Despite temporary transvenous pacing, her complete atrioventricular block persisted, but worsening of heart failure did not occur. Although left ventricular wall motion improved, complete atrioventricular block remained, so a pacemaker was implanted on day 18 after admission. There have been no previous reports of complete atrioventricular block associated with midventricular ballooning. This case demonstrates that complete atrioventricular block may persist after improvement of left ventricular wall motion in patients with midventricular ballooning and implantation of a pacemaker may be needed. .

Infectious endocarditis caused by Lactobacillus acidophilus in a patient with mistreated dental caries.

We present a rare case of infectious endocarditis caused by Lactobacillus acidophilus in a patient on long-term steroid use for autoimmune hepatitis. In vitro susceptibility-guided antibiotics with benzylpenicillin plus clindamycin and successive mitral annuloplasty resulted in a favorable outcome. Infectious endocarditis was suspected to be a complication of mistreated periodontal infection. Maintenance of oral hygiene is important in immunocompromised patients.

Coexistent true aortic aneurysm as a cause of acute aortic dissection.

BACKGROUND: Aortic aneurysms are found in 5-20% of patients with acute aortic dissection (AAD). Coexisting aortic aneurysms might potentially influence the incidence of AAD. The purpose of this study was to elucidate the role of coexistent aortic aneurysms in AAD. METHODS AND RESULTS: A total of 140 patients with AAD were enrolled in the present study. Clinical characteristics of the patients were evaluated in relation to the locations of aortic segments affected by the dissection as well as of the coexistent aortic aneurysm. Among the 140 study patients, 34 (24%) had true aortic aneurysms. Patients with coexistent aortic aneurysm were significantly older than those without (72 +/- 11 years vs 65 +/- 14 years, P=0.012) and had higher incidence of thrombosed false lumen (62% vs 38%, P=0.017), and coronary artery disease (26% vs 8%, P=0.006). Twenty-two of these 34 (65%) patients had a thoracic aortic aneurysm (TAA), and this frequency of TAA was much higher than that observed in the general population. Furthermore, among all patients with AAD, 12 patients (9%) might be associated with development of AAD. CONCLUSIONS: The current study showed that nearly one-quarter of AAD patients had coexisting true aortic aneurysms, and suggests that TAA are likely to be associated with development of AAD.

Patients with peripheral artery disease who complete 12-week supervised exercise training program show reduced cardiovascular mortality and morbidity.

BACKGROUND: Exercise training improves walking ability in patients with peripheral arterial disease (PAD), but whether exercise training improves the long-term outcome of these patients remains unknown. METHODS AND RESULTS: Participants were 118 PAD patients who were enrolled in a 12-week supervised exercise program. The long-term outcomes of 64 patients who completed the training were compared with the outcomes of 54 patients who did not. The primary endpoint was cardiovascular mortality, and the secondary endpoint was cardiovascular morbidity. Mean follow-up was 5.7+/-3.9 years. The cardiovascular death-free rate was higher in patients who completed the training program than in those who did not (P=0.022). Multivariate analysis showed independent predictors of cardiovascular death were age over 70 years, diabetes mellitus, maximum walking distance, history of coronary revascularization, and completion of training program. The cardiovascular event-free rate was also higher in patients who completed the training program (P=0.048). CONCLUSIONS: Supervised exercise training improved cardiovascular mortality and morbidity in patients with PAD, which suggests that exercise training should be considered as a secondary prevention strategy for these patients.

Usefulness of fibrinogen/fibrin degradation product to predict poor one-year outcome of medically treated patients with acute type B aortic dissection.

Previous studies have indicated that medical therapy provides excellent outcomes for patients with uncomplicated Stanford type B acute aortic dissection. However, affected aortas are often compromised by aneurysmal dilatation and rupture, resulting in poor outcomes. The purpose of this study was to determine predictors of aortic events in patients with Stanford type B acute aortic dissection receiving conservative medical therapy. The study group consisted of 78 consecutive patients with Stanford type B acute aortic dissection who were admitted to the hospital within 48 hours of onset. These patients were treated medically and followed up for 1 year. Aortic events were defined as rupture, recurrent dissection, aortic expansion with diameter>or=60 mm, rapid aortic expansion at a rate of >or=10 mm/yr, and the development of visceral or limb ischemia. Predictors of these events were determined using multivariate analyses. During 1-year follow-up, aortic events were observed in 13 (17%) patients, including aortic rupture in 3 (4%), aortic diameter>or=60 mm in 4 (5%), rapid expansion of the aorta in 3 (4%), and the development of visceral or limb ischemia in 3 (4%). On multivariate analysis, fibrinogen-fibrin degradation product level>or=20 microg/ml (odds ratio 7.802, 95% confidence interval 1.405 to 43.335) on admission was the only independent predictor of aortic events at 1 year. In conclusion, careful monitoring is required for patients with medically treated Stanford type B acute aortic dissection associated with fibrinogen-fibrin degradation product level>or=20 microg/ml on admission.

Long-term outcome after percutaneous peripheral intervention vs medical treatment for patients with superficial femoral artery occlusive disease.

BACKGROUND: Percutaneous peripheral intervention (PPI) for superficial femoral artery (SFA) stenosis is associated with a high restenosis rate. Whether PPI improves the long-term outcome of patients with SFA occlusive disease remains to be determined. METHODS AND RESULTS: A review was done of 107 patients with SFA occlusive disease. Fifty-five patients received PPI for SFA (ie, PPI group) and 52 patients received conservative medical therapy (ie, control group). Clinical records were searched for adverse events (eg, death, limb amputation, re-hospitalization, new onset of coronary artery disease and cerebrovascular disease) for an average of 30.6+/-17.7 months. At follow-up, only 5 patients (9.1%) in the PPI group experienced improved limb symptoms compared with baseline, and 6 patients (10.9%) showed ischemic skin ulcer or gangrene. In addition, 2 of these 6 patients were unsuccessful PPI cases complicated with distal embolization and perforation. In the control group, 3 patients (5.8%) presented with improved limb symptoms, and an equal number of patients had worsening of symptoms. Although 2 patients showed ischemic skin ulcers at follow-up, both patients had these lesions at baseline. Adverse events were observed more frequently in the PPI group than the control group (69.1% vs 46.2%, p<0.05). This was mainly due to a higher frequency of re-hospitalization in the PPI group than in controls (52.7% vs 15.4%, p<0.001). CONCLUSIONS: The current study demonstrates that PPI for patients with SFA occlusive disease does not provide superior long-term benefits compared with conservative medical therapy, and that medical therapy will continue to remain the primary treatment strategy for this group of patients.

Differences in atherosclerotic profiles between patients with thoracic and abdominal aortic aneurysms.

Differences in atherosclerotic profiles between patients with thoracic aortic aneurysm (TAA) and patients with abdominal aortic aneurysm (AAA) have not been studied. We retrospectively studied the clinical records of 343 consecutive patients (132 TAA and 211 AAA) who were admitted to our hospital for elective repair of aortic aneurysms between July 2001 and December 2004. Clinical variables were compared between patients with TAA and those with AAA by using a univariate analysis, and those achieving statistical significance were subsequently assessed in a multivariate analysis. The incidence of coronary artery disease (CAD) (53% vs 23%, p <0.0001), 3-vessel coronary disease (41% vs 10%, p <0.0001), male gender (86% vs 74%, p <0.01), smoker (88% vs 76%, p <0.01), chronic obstructive pulmonary disease (COPD) (30% vs 15%, p <0.01), and diabetes mellitus (39% vs 23%, p <0.01) were significantly higher in patients with AAA than in those with TAA. In contrast, the incidence of hypertension (91% vs 81%, p <0.05), saccular-type aneurysm (61% vs 7%, p <0.0001), and body mass index (24.1 +/- 3.1 vs 23.2 +/- 3.5, p <0.05) were significantly higher in patients with TAA than in those with AAA. Multivariate stepwise logistic analysis revealed that CAD (odds ratio [OR] 3.65; 95% confidence interval [CI] 2.12 to 6.42; p <0.0001), COPD (OR 2.05; 95% CI 1.11 to 3.89; p <0.05), and diabetes mellitus (OR 1.85; 95% CI 1.06 to 3.27; p <0.05) were associated with AAA, and that body mass index (OR 9.39; 95% CI 2.0 to 46.8; p <0.01), hypertension (OR 3.09; 95% CI 1.48 to 6.87; p <0.01), and cerebral infarction (OR 2.83; 95% CI 1.25 to 6.50; p <0.05) were associated with TAA. In conclusion, atherosclerotic profiles are significantly different between patients with TAA and patients with AAA. This result suggests the possibility that mechanisms underlying the development of aortic aneurysms may differ between TAA and AAA, and, from the perspective of prevention, provides further stimulus for the modification of key risk factors for atherosclerosis.

A case of acute type B aortic dissection: limited role of laboratory testing for the diagnosis of mesenteric ischemia.

A 30-year-old man with severe back and abdominal pain was referred to our hospital because of a recurrence of acute type B aortic dissection. A computed tomography scan showed a 3-channel dissection and a severe narrowing of the true lumen of the descending aorta to the abdominal aorta because of the expansion of the newly formed second false lumen. Although laboratory testing, including creatine phosphokinase, lactate dehydrogenase, and lactate levels, indicated no visceral ischemia, abdominal pain requiring narcotics treatment had to be continued for more than 1 week. Based on the symptoms and computed tomography findings, the patient finally underwent aortic replacement, fenestration, and a reconstruction of the inferior mesenteric artery, after which the abdominal pain disappeared. Operative findings confirmed a pale shrunken intestine, indicative of mesenteric ischemia. The present case is a good demonstration revealing that mesenteric ischemia still remains a diagnostic challenge, and suggests that currently available laboratory markers are not sensitive enough to detect the presence of ischemia. A strong clinical suspicion for mesenteric ischemia may be the only key to preventing a catastrophic outcome in this condition.

Phenotypic heterogeneity of Marfan-like connective tissue disorders associated with mutations in the transforming growth factor-beta receptor genes.

BACKGROUND: Mutations in the genes for transforming growth factor-beta receptor (TGFBR) have been identified in patients with Marfan syndrome (MFS) and Marfan-like connective tissue disorders. There are several syndromes associated with mutations in TGFBR genes, including Loeys-Dietz syndrome (LDS), MFS2, Furlong syndrome, and Shprintzen-Goldberg syndrome. However, with the exception of the first report by Loeys et al, the phenotypic features of patients with TGFBR gene mutations have not been precisely reported. METHODS AND RESULTS: A total of 18 patients suspected of having MFS were recruited and 7 were diagnosed with MFS and mutations in FBN1. Among the remaining 11 patients, 1 patient had mutations in TGFBR1, 2 had mutations in TGFBR2, and 1 had mutations in COL3A1. The clinical manifestations of the 3 patients with TGFBR gene mutations were examined according to the list of 36 clinical features described in the first report by Loeys et al. The clinical manifestations of these 3 patients differed from those previously observed in patients with MFS2, Furlong syndrome, and Shprintzen-Goldberg syndrome. Thus, the most probable diagnosis of these 3 patients was LDS, despite the fact that they presented with only a fraction of the 36 clinical features associated with LDS. CONCLUSIONS: Although the number of the patients was limited, the findings support the notion that mutations in the TGFBR gene may be associated with greater phenotypic heterogeneity than previously reported.