Acute progression of cerebral amyloid angiopathy-related inflammation diagnosed by biopsy in an elderly patient: A case report.

Background: Cerebral amyloid angiopathy-related inflammation (CAA-I) presents with slowly progressive nonspecific neurological symptoms, such as headache, cognitive function disorder, and seizures. Pathologically, the deposition of amyloid-ß proteins at the cortical vascular wall is a characteristic and definitive finding. Differential diagnoses include infectious encephalitis, neurosarcoidosis, primary central nervous system lymphoma, and glioma. Here, we report a case of CAA-I showing acute progression, suggesting a glioma without enhancement, in which a radiological diagnosis was difficult using standard magnetic resonance imaging. Case Description: An 80-year-old woman was admitted due to transient abnormal behavior. Her initial imaging findings were similar to those of a glioma. She presented with rapid progression of the left hemiplegia and disturbance of consciousness for 6 days after admission and underwent emergent biopsy with a targeted small craniotomy under general anesthesia despite her old age. Intraoperative macroscopic findings followed by a pathological study revealed CAA-I as the definitive diagnosis. Steroid pulse therapy with methylprednisolone followed by oral prednisolone markedly improved both the clinical symptoms and imaging findings. Conclusion: Differential diagnosis between CAA-I and nonenhancing gliomas may be difficult using standard imaging studies in cases presenting with acute progression. A pathological diagnosis under minimally invasive small craniotomy may be an option, even for elderly patients.

Peritonitis is still an important factor for withdrawal from peritoneal dialysis therapy in the Tokai area of Japan.

BACKGROUND: In Japan, the population of patients on peritoneal dialysis (PD) is <4% of the total number of patients with end-stage renal disease. Few systemic analyses have examined why the number of PD patients has not increased in Japan. We organized a registry to analyze PD patients and retrospectively investigated 561 PD patients (about 5% of all Japanese PD patients) from 13 hospitals in the Tokai area for 3 years from 2005. METHODS: We investigated background, physical status, laboratory data, status of PD therapy, and the occurrence of PD-related complications, and analyzed reasons for withdrawal from PD. RESULTS: Nutrition did not change significantly during our observation. Urinary volume showed continued decreases after the introduction period. In contrast, PD fluid demand and ultrafiltration volume were significantly increased. For calcium metabolism, multiple phosphate binders were required after the second year of PD therapy. Early drop-out within 3 years after starting PD therapy comprised 50.9% of total withdrawals, with PD-related peritonitis as the most common reason, mainly caused by Gram-positive organisms. Incidence of peritonitis was 42.8 months/patient. Culture-negative results were obtained for 32% of peritonitis cultures. Diabetes affects the prognosis of PD therapy, but not the incidence of peritonitis. CONCLUSION: We examined clinical status over 3 years in the Tokai area. The results suggest that the incidence of peritonitis needs to be decreased to prevent early withdrawal of PD patients. Education systems to decrease the incidence of peritonitis and techniques to decrease culture-negative results might be important for improving the prognosis of peritonitis.

Severe coronary stenosis is an important factor for induction and lengthy persistence of ventricular arrhythmias during and after hemodialysis.

BACKGROUND: Ventricular arrhythmias have been shown to be the major cause of sudden cardiac death in hemodialysis (HD) patients. We investigated whether angiographic coronary stenosis was responsible for the induction of ventricular arrhythmias in HD patients. METHODS: HD patients (n = 150) showing ischemic signs in exercise electrocardiography or echocardiography were divided into 2 groups: the stenotic group (n = 61), with significant coronary stenosis (> or =75% in diameter), and the nonstenotic group (n = 89), without significant coronary stenosis on coronary angiography. Severity of ventricular arrhythmias was evaluated by means of ambulatory 24-hour Holter monitoring in HD patients with and without significant coronary stenosis. RESULTS: The frequency of ventricular premature contractions and prevalence of patients with Lown class 4 ventricular arrhythmias were significantly greater in the stenotic than nonstenotic group during HD and for 12 hours after HD (P < 0.03). In the stenotic group, a significantly greater frequency of ventricular premature contractions and prevalence of patients with complex arrhythmias were observed during HD (1.33% and 31.1%, respectively) compared with before HD (0.50% and 11.5%, respectively), and the high incidence persisted for 6 hours after HD. In the nonstenotic group, a slightly increased incidence was observed only during HD compared with before HD. Multivariate analysis showed only coronary stenosis (odds ratio, 5.69; P = 0.041) as an independent and significant factor for the induction of complex arrhythmias. CONCLUSION: These data clearly indicate that severe coronary stenosis, which may cause myocardial ischemia, is an important factor for the induction and lengthy persistence of ventricular arrhythmias during and after HD.

Non-dipping is a potent predictor of cardiovascular mortality and is associated with autonomic dysfunction in haemodialysis patients.

BACKGROUND: Lack of nocturnal blood pressure (BP) fall (non-dipping) is common among haemodialysis (HD) patients, but much less is known regarding its association with cardiovascular (CV) disease morbidity and mortality. METHODS: Eighty HD patients initially underwent 24 h ambulatory BP monitoring (ABPM), and then they were defined as either 'dippers' (n=24, nocturnal BP fall > or = 10%) or 'non-dippers' (n=56, fall <10%). Coronary angiography was performed in the patients who had signs and/or symptoms of coronary artery disease (CAD). Twenty-four hour ambulatory ECG was recorded in 20 dippers and 20 non-dipper HD patients, and in 20 normal subjects. All patients were followed for up to 5.8 years (33.0+/-19.1 months). The outcome events studied were the hospitalisations due to CV diseases and CV death. RESULTS: Compared with dippers, non-dippers initially had a higher incidence of coronary artery stenosis (P<0.05) along with left ventricular asynergy (both Ps<0.01). The circadian rhythm of autonomic function was impaired in non-dippers. The incidences of CV events and CV deaths were 3.5 and 9 times higher in non-dippers than in dippers. The cumulative CV event-free survival and CV survival rates were lower in non-dippers than in dippers (P=0.02 and P=0.005, respectively). Based on Cox analysis, non-dipping was associated positively with CV events and CV mortality [hazard ratio (HR) 2.46, 95% CI 1.02-5.92, P=0.038 and HR 9.62, 95% CI 1.23-75.42, P=0.031, respectively]. Meanwhile, nocturnal systolic BP fall, diurnal systolic BP and diurnal pulse pressure were negatively associated with CV event/death. The clinic BP was not associated with CV event/death. CONCLUSIONS: The non-dipping phenomenon is closely related to a high incidence of CV diseases, a poor long-term survival and profound autonomic dysfunction. ABPM is useful in predicting long-term CV prognosis in HD patients.