Changes of alpha1-protease inhibitor and secretory leukocyte protease inhibitor levels in gingival crevicular fluid before and after non-surgical periodontal treatment.

OBJECTIVES: The possible contribution of alpha1-protease inhibitor (alpha1-PI) and secretory leukocyte protease inhibitor (SLPI) in gingival crevicular fluid (GCF) to predict the periodontal disease activity was evaluated. DESIGN: GCF samples were collected at each site before scaling and root planning (SRP), 2 and 4 weeks after SRP. SUBJECTS AND METHODS: Forty-one sites that initially bled on probing in 21 patients with moderate to severe periodontitis were studied. Sites were classified according to the presence or absence of bleeding on probing (BOP) at 4 weeks. In GCF alpha1-PI and SLPI were determined by enzyme-linked immunosorbent assays. RESULTS: A significant decrease was observed in alpha1-PI at 2 and 4 weeks in BOP(-) sites and at 4 weeks in BOP(+) sites. SLPI significantly increased at 2 weeks in BOP(+) site, while SLPI did not significantly differ at both time points in BOP(-) sites and at 4 weeks in BOP(+) sites. GCF alpha1-PI was significantly less at 2 weeks in BOP(-) than in BOP(+) sites. CONCLUSION: At 2 weeks GCF alpha1-PI may reflect the healing response of the periodontal tissues following nonsurgical periodontal treatment. GCF SLPI levels may be influenced by healing.

Nephrotic syndrome due to focal glomerulosclerosis and undifferentiated carcinoma.

In neoplastic disorder-related nephrotic syndrome, focal glomerulosclerosis (FGS) has been reported mainly in hematological disorders like minimal change nephrotic syndrome (MCNS) in association with presumed T lymphocyte dysfunction. The association of FGS with cancer or solid tumor is rare. We report a case of nephrotic syndrome due to FGS in a patient with undifferentiated adenocarcinoma of the cystic duct. Although the underlying mechanism is unclear, the development of FGS seemed to be related to the poor histological differentiation of the cancer in the possibility of production of an active peptide.

Electrolyte disorders following massive insulin overdose in a patient with type 2 diabetes.

We present a case of a 47-year-old man with Type 2 diabetes mellitus who attempted suicide with 2,100 U of insulin injected subcutaneously. Administration of dextrose intravenously was required to maintain the blood glucose concentration normally for 5 days. Moreover, hypokalemia, hypophosphatemia, and hypomagnesemia were also seen for 24 hours after insulin injection. The serum phosphorus and magnesium concentrations decreased to nadirs of 1.6 mg/dl and 1.6 mg/dl respectively 7 hours after insulin injection. Electrolyte disorders other than hypokalemia may be induced in hypoglycemic patients by massive insulin overdose.

[An elderly case of idiopathic thrombocytopenic purpura associated with acute myocardial infarction].

We report a rare case of idiopathic thrombocytopenic purpura (ITP) associated with acute myocardial infarction (AMI). A 72-year-old woman with hypertension and hemorrhoids was admitted because of chest pain, severe anemia (RBC 340 x 10(4)/microliter, Hb 5.4 g/dl, Ht 21.7%) and thrombocytopenia (0.2 x 10(4)/microliter). AMI was diagnosed by electrocardiogram (ST elevation and negative T in V2-5), echocardiogram (hypokinesis in anteroseptal wall) and laboratory (CPK 470 U/l) findings and was treated with only blood transfusion. Chest pain disappeared the day after admission, and neither heart failure nor arrhythmia occurred. Based on bone marrow findings (hyperplasia of erythroblast and megakaryocyte), endoscopic (internal hemorrhoids) and laboratory (antiplatelet antibody positive, platelet associated IgG 257.8 ng/10(7) cells) findings, iron deficiency anemia and ITP were diagnosed. Anemia improved after blood transfusion, but thrombocytopenia (< 1.0 x 10(4)/microliter) without active bleeding continued after steroid and gamma-globulin therapy. At discharge, electrocardiogram showed a negative T in I, aVL and V2-5, and T1 and BMIPP myocardial scintigram showed defects in the anteroseptal and apical wall.

[201Tl SPECT for suspected lung cancer in a case of a systemic arterial supply to the lung without sequestration].

201Tl SPECT showed negative result for the presence of a malignant lesion in a 54-year-old male suspected with primary lung cancer on plain x-ray CT. Thin-section contrast x-ray CT and aortography revealed anomalous left lower pulmonary artery arising from the aorta which mimicked a pulmonary mass lesion in the initial study. 201Tl SPECT gave us a clue to the correct diagnosis.

Intense and prolonged Tl-201 accumulation in a slow growing bronchioloalveolar carcinoma.

Thallium-201 SPECT was performed to evaluate a pulmonary lesion in a 73-year-old male which had been considered to be an inflammatory lesion for two years. The lesion has slowly increased in size on x-CT. Tl-201 was intensely taken up and retained in the lesion, suggesting a malignant lesion. Histological examination revealed that the lesion was bronchioloalveolar carcinoma. This case suggested that Tl-201 uptake of pulmonary carcinoma would not be necessarily related to cell growth rate.

[A case of multiple myeloma associated with abnormal plasma cells and M-protein in pleural effusion].

A 77-year-old woman with hypertension was admitted to our hospital because of exertional dyspnea end peripheral edema. Chest X-ray showed cardiomegaly, pulmonary congestion and right pleural effusion. Hypertensive heart failure was diagnosed and treated, and right pleural effusion disappeared in 2 weeks. Abnormalities on laboratory data, i.e. anemia and increased ESR et al. continued after the improvement of heart failure. Serum IgG was elevated (2570 mg/dl), while IgA and IgM were decreased. Immunoelectrophoresis indicated the presence of monoclonal IgG-lambda in the serum. Bone marrow puncture revealed an increase in atypical plasma cells (38.4%). Multiple myeloma was diagnosed from these findings and treated with melphalan and prednisolone. But increases in atypical plasma cells (43.2%) and serum IgG (2573 mg/dl) continued. During treatment, right pleural effusion increased again. Thoracocentesis showed bloody effusion with numerous atypical plasma cells, and the presence of monoclonal IgG-lambda was indicated by immunoelectrophoresis. The patient died of renal and heart failure 2 months after the onset of malignant pleural effusion. Cytological examination and immunoelectrophoresis are necessary for pleural effusion in multiple myeloma.

[An 85-year-old case of Basedow's disease associated with high output heart failure and angina pectoris].

We report a rare case of Basedow's disease associated with high output heart failure and angina pectoris over the age of 80 years. An 85-year-old woman was admitted with palpitation, finger tremor, hyperidrosis and weight loss. Basedow's disease was diagnosed by physical (diffuse goiter) and laboratory (free T3 19.4 pg/ml, free T4 > 8.0 ng/dl, TSH < 0.1 microU/ml, TRAb positive, 123I uptake high) findings and was treated with methimazole. Chest oppression and dyspnea on exertion with negative T wave, cardiomegaly and pulmonary congestion appeared after methimazole. Cardiac catheterization showed a high cardiac output (CI 5.01/min/m2, PCW 26 mmHg, PA 57/26 mmHg, RA 15 mmHg) and a significant coronary stenosis (LAD [symbol: see text] 99%). High output heart failure and angina pectoris responded to treatment. They subsequently worsened, because she stopped taking methimazole for a month and serum levels of thyroid hormones increased again. After retreatment with methimazole, serum levels of thyroid hormones decreased to within normal limits, and high output heart failure and angina pectoris also improved.

[Renal diseases in disturbance of urate metabolism].

Although serum concentrations of uric acid could be frequently measured in various diseases, most clinicians are less interesting in the significance of serum urate levels. Since uric acid is produced in the body and eliminated through the kidney into the urine, the kidney plays a main role in controlling serum urate level. On the other hand higher concentrations of uric acid in blood and urine could involve renal damage because uric acid is less soluble in acidic solutions like a tubular fluids, resulting in tubulointerstitial nephropathy. In this paper I described that the mechanism of urate metabolism in the human kidney and then how disorders of urate metabolism involve the kidney.

[Gastroesophageal reflux and respiratory tract infection in tube-fed elderly patients--a comparison between scintigraphy and 24-h pH monitoring].

Aspiration pneumonia in patients who received enteral feeding via a nasogastric tube may result from retrograde colonization from the stomach, and this may be more likely when the gastroesophageal reflux is severe and the gastric pH is relative high. We investigated 11 elderly patients fed via nasogastric tube with suspected recurrent aspiration pneumonia by means of esophageal scintigraphy, 24-h pH monitoring, gastric pH and concentrations of gram-negative bacilli in gastric aspirates. The grade of respiratory tract infection (RTI) was evaluated by the frequency of episodes of fever with respiratory symptoms. The correlation between the grade of RTI and reflux index by scintigraphy was statistically significant (p < 0.05), but the correlation between the grade of RTI and reflux rate by 24-h pH monitoring was not statistically significant. Although the correlation between gastric pH and log (base 10) concentration of gram-negative bacilli/ml of gastric aspirates was statistically significant (p < 0.001), the correlation between the grade of RTI and gastric pH was not statistically significant. Scintigraphy was superior for evaluation of gastroesophageal reflux resulting in aspiration pneumonia in the tube-fed elderly patients.

[A case of renal hypouricemia associated with IgA nephropathy--with special reference to changes in serum uric acid and uric acid clearance in a clinical course exceeding 15 years].

We report a case of IgA nephropathy associated with renal hypouricemia. The patient's renal function had decreased gradually during the previous 15 years, resulting in chronic renal failure. Levels of serum uric acid and uric acid clearance were 1.0 mg/dl and 39.4 ml/min, respectively. Pyrazinamide suppression test indicated that the patient had defective tubular reabsorption of uric acid at the presecretory site. The serum uric acid level elevated linearly to 5.0 mg/dl during the 15-year period, in parallel with a change in serum creatinine level, giving a significantly positive correlation coefficient of 0.9776. The ratio of uric acid and creatinine clearances showed no significant change, although both decreased during the 15 years. These results were a different from those in patients with chronic glomerulonephritis, including IgA nephropathy, where the serum uric acid level had shown no significant correlation with serum creatinine level above 2.0 mg/dl and the ratio of uric acid clearance and creatinine clearance had exponentially elevated after the latter decreased below 30-40 ml/min. The patient presented here has defective tubular transport of uric acid at the site of urate reabsorption, and appears to show a different tubular dysfunction response from patients with chronic glomerulonephritis and decreased renal function.

[Guanidino compounds in the elderly].

To examine the metabolism of guanidino compounds in the elderly, we measured the serum concentrations of urea nitrogen, creatinine (Cr), guanidinoacetic acid (GAA) and creatine (CR) in middle-aged and elderly subjects. We also measured muscle mass in the elderly. The elderly subjects tended to have lower serum GAA concentrations than middle-aged subjects. On the contrary, CR concentrations of elderly subjects were higher than those of middle-aged subjects. Bedridden elderly subjects tended to have lower serum GAA concentrations and lighter muscle mass than ambulatory elderly subjects. On the contrary, serum CR concentrations of bedridden subjects were higher than those of ambulatory subjects. CR is an essential substance for muscle energy metabolism. These results indicate that high serum CR concentrations due to low CR metabolism in skeletal muscle might suppress glycine amidinotransferase (GAT) activity, resulting in decreased GAA production in the elderly.

Hereditary angioedema complicated with chronic renal failure: report of sibling cases.

Hereditary angioedema (HAE) is known as a deficiency state of C1 inhibitor (C1 INH), an important protease inhibitor protein involved in the complement system. As with other components of the classical pathway of the complement system, a state of its deficiency often causes clinical immunoregulatory disorders. A 45-yr-old brother and a 63-yr-old sister with HAE both developed chronic renal failure, probably due to chronic glomerulonephritis, and required regular hemodialysis. This is, to our knowledge, the first report of sibling cases of HAE associated with chronic renal failure.

Urine anion gap in patients with chronic renal insufficiency.

We investigated the urinary acid excretion and urine anion gap (AG) (Na+ + K(+)-Cl-) during NH4Cl-induced metabolic acidosis in 38 normal subjects and 53 patients with chronic renal diseases in order to clarify the significance of the urine AG as a useful marker of the ammonium (NH4+) excretion even in a state of chronic renal insufficiency. The urine pH became higher, and the urinary excretions of titratable acid (TA) and NH4+ decreased significantly, in parallel with a reduction of the creatinine clearance (Ccr). The urinary electrolyte excretion, especially the chloride excretion, also decreased significantly as Ccr fell. As a result, the urine AG increased from negative to positive values, in proportion to the decrease in Ccr with statistical significance. The urine AG showed the most significant correlation with the urine NH4+ excretion (r = -0.707, p less than 0.001). We conclude that the urine AG provides a significant marker of the urine NH4+ excretion even in a state of moderate to severe renal insufficiency.