A case of adrenal tumor producing renin, aldosterone, and sex steroid hormones.

A 27-year-old woman with an adrenal tumor that produced renin and aldosterone, associated with hypertension and adrenogenital syndrome, is described. Severe hypertension, cardiomegaly, a low serum potassium level, clinical symptoms of adrenogenital syndrome, and a left upper abdominal tumor also were found. Endocrinological studies showed that plasma and urinary levels of sex steroid hormones such as dehydroepiandrosterone, androsterone, and testosterone were markedly increased. Plasma renin activity, plasma angiotensin II, and plasma aldosterone levels also were increased markedly, although deoxycorticosterone levels remained within the normal range. The possibility of renovascular hypertension was excluded by angiography of the renal artery and by venous sampling of plasma renin activity. Abnormal elevations in plasma aldosterone levels persisted despite normalization of plasma angiotensin II by converting enzyme inhibitor administration. It was suspected that this patient had an adrenal tumor producing renin as well as sex steroids and aldosterone. Microscopy of the resected tumor revealed that the tumor was composed mostly of cells with large nuclei and light cytoplasm. The tumor contained dehydroepiandrosterone, dehydroepiandrosterone sulfate, testosterone, aldosterone, and renin. Immunohistochemical study showed that some of the tumor cells produced renin. Biopsy of the left renal tissue showed evident atrophy of the juxtaglomerular cells and pronounced arteriosclerosis. After resection of the tumor, all blood and urinary levels of the abnormally increased hormones returned to a normal range and an apparent fall of blood pressure was noted. To our knowledge, this is the first report of a renin and aldosterone-producing adrenal tumor associated with hypertension and adrenogenital syndrome.

Validity of catheter-tip Doppler technique in assessment of coronary flow velocity and application of spectrum analysis method.

Measurement of coronary flow velocity in clinical cases contributes to understanding the pathophysiology of coronary circulation. To determine absolute coronary flow velocity, coronary blood flow was assessed with an end-mounted Doppler catheter (3Fr, 20 MHz), which was combined with a custom-designed fast-Fourier transformation analysis system. In vitro study using model circuit, actual flow velocity (8 to 96 cm/s) was well correlated with that determined by this catheter system (y = 1.01 X +1.5, r = 0.988). In a clinical study of 12 patients with normal coronary arteriograms, the Doppler catheter was positioned at the proximal left anterior descending artery. Clear flow velocity patterns, which consisted of predominant diastolic components and preceding small systolic components, were obtained in all cases. The peak flow velocity was 17 +/- 8 cm/s (mean +/- standard deviation) during systole and 44 +/- 12 cm/s during diastole in this portion. In 5 patients, the great cardiac vein flow, which reflects the left anterior descending artery flow, was simultaneously measured during rapid atrial pacing. During pacing, percent increases in flow velocity were well correlated with those in great cardiac vein flow (y = 0.90 x +6.4, r = 0.935). These results indicate that catheter-tip Doppler technique with fast-Fourier transformation analysis may be useful in quantitatively determining coronary flow velocity in clinical cases.

Effect of superoxide dismutase plus catalase on myocardial infarct size in rabbits.

A previous study by the authors showed that myocardial infarct size in the rabbit, measured after 45 mins of ischemia and 3 h of reperfusion, could be limited by administration of superoxide dismutase (SOD) plus catalase. The present study examined whether this infarct size limitation is sustained for the following three days. Under anesthesia, a coronary branch of the Japanese white rabbit was occluded for 45 mins and then reperfused. Three days after surgery, the heart was excised and the volume of myocardium supplied by the occluded coronary branch (ischemic zone size) was assessed with fluorescent particles and the infarct size was estimated by hematoxylin and eosin and with Mallory's staining. The SOD plus catalase group (n = 14) received 15,000 units/kg of SOD plus 50,000 units/kg of catalase in saline over 90 mins, starting 15 mins before the coronary occlusion. Saline was infused in the control group (n = 15). Three rabbits in the control group and three in the SOD plus catalase group died of ventricular fibrillation during the ischemic period. Three control and two SOD plus catalase rabbits were excluded because the ischemic zone was ambiguous. The percentage of the ischemic zone which was infarcted was 59.4 +/- 6.9% (mean +/- SE) in the control group (n = 9) and 49.4 +/- 5.1% in the SOD plus catalase group (n = 9). These were not statistically different. Ischemic zone size and hemodynamic parameters were similar in the two groups. These findings suggest that SOD plus catalase may serve only to delay rather than prevent myocardial infarction.

Slow continuous hemodialysis--new therapy for acute renal failure in critically ill patients--Part 2. Animal experiments and clinical implication.

Five acutely uremic dogs were treated for 9 hours by means of slow continuous hemodialysis using our newly developed machine. The blood concentrations of urea nitrogen (BUN) and creatinine were determined every hour and were compared to those calculated from a mathematical pool model. In order to assess the accuracy of volume control, the body weight of dogs was monitored continuously by scale bed, under simultaneous 200 ml/hour infusion and ultrafiltration. Arterial and swan-ganz catheter were inserted to measure hemodynamic changes during hemodialysis. The efficacy of solute elimination was coincidental with the predicted value. The error of volume control was within +/- 5% of set rate. Hemodynamic parameters were not significantly influenced in spite of a large amount of volume exchange. In conclusion, it was demonstrated that slow continuous hemodialysis could be a better alternative to peritoneal dialysis, continuous hemofiltration or conventional hemodialysis in order to treat acute renal failure in critically ill patients, in terms of solute removal, volume control and the effects on hemodynamics.

Early afterdepolarization in a patient with complete atrioventricular block and torsades de pointes.

We present a patient with complete atrioventricular block and torsades de pointes in whom early afterdepolarization (EAD) was demonstrated in right ventricular monophasic action potentials (MAPs). In an emergency situation, MAPs were recorded after the suppression of torsades de pointes by magnesium injection. EADs were observed at three out of five right ventricular sites during escape rhythm. Thus, magnesium abolished the tachycardia without shortening the QT interval and probably without suppressing EAD. Right ventricular pacing and the injection of lidocaine (50 mg) suppressed EAD and shortened the QT interval.

Technetium-99m sestamibi/tetrofosmin myocardial perfusion scanning in cardiac and noncardiac sarcoidosis.

Left ventricular (LV) and right ventricular (RV) involvement in sarcoidosis must be firmly confirmed to determine patients' prognosis. We examined whether myocardial perfusion images using technetium-99m single photon emission computed tomography (SPECT) have a diagnostic benefit in the evaluation of biventricular involvement. Sixteen patients with sarcoidosis, aged 21-78 (54 +/- 12) years old, 5 males and 11 females, complicated with cardiac disease (cardiac sarcoidosis, n = 6) including tachyarrhythmias of ventricular origin (n = 5), atrioventricular block (n = 4), and congestive heart failure (NYHA > or = II, n = 1), were enrolled in this study. Myocardial SPECT using technetium-99m sestamibi or tetrofosmin was performed and semiquantitatively scored for comparison with 25 control subjects. Perfusion abnormalities were more frequently recognized in sarcoidosis (LV 5/16, 31% and RV 14/16, 88% vs. LV 0/25, 0% and RV 8/25, 32% in controls). LV involvement had a close correlation with atrioventricular block and with congestive heart failure, and multiple sites of RV involvement correlated with ventricular tachyarrhythmia of RV origin. Total number of defect segments were highest in cardiac sarcoidosis (18/30, 60% vs. 19/60, 32% in noncardiac sarcoidosis, and 11/150, 7% in controls, p = 0.0001), and semiquantitatively evaluated total LV and RV scores (ranging from 0 to 18) were higher than those of controls (15.1 +/- 1.8 vs. 11.4 +/- 3.0 in noncardiac sarcoidosis, and 9.0 +/- 5.0 in cardiac sarcoidosis) and exhibited a significant positive linear correlation with the RV ejection fraction (y = 19.8 + 1.83x, r = 0.786, p = 0.001). Biventricular SPECT using technetium-99m is clinically useful for the noninvasive evaluation of both ventricular involvements in sarcoidosis.