Enzyme activities related to glucose metabolism in Babesia microti and Babesia rodhaini.

A comparative study was carried out on the glucose metabolism in Babesia microti (BM) and Babesia rodhaini (BR) by analyzing the enzyme activities. The lactate dehydrogenase (LDH) activity in BM showed significantly lower values than that in BR, whereas citrate synthase (CS) and malate dehydrogenase (MDH) activities were remarkably higher in BM. In addition, pyruvate dehydrogenase (PDH), isocitrate dehydrogenase (ICDH), alpha-ketoglutarate dehydrogenase (KGDH), and succinate dehydrogenase (SDH) activities also tended to be higher in BM. Then, the change of enzyme activities related to the proliferation of parasites was examined. In BM infected mice, the parasitemia increased from day 15 to day 19 after inoculation (a.i.). While BM showed decrease of G6PD and LDH activities at day 19 a.i., it showed remarkably increased activities in CS and MDH (368 and 8,842 nmol/min.mg protein, respectively). In addition, PDH, ICDH, KGDH, and SDH activities also tended to increase from day 15 to 19 a.i. In BR infected mice, parasitemia increased from day 9 to day 12 a.i. LDH activity showed a considerable increase at day 12 a.i. (12,920 IU/mg.protein). Although CS and MDH activities also showed a slight increase at day 12 a.i., the activities of PDH, ICDH, KGDH and SDH didn't change from day 9 to 12 a.i. Since these changes observed in the enzyme activities of BM and BR seemed to be correlated with their proliferation, it was suggested that BM and BR depended on aerobic and anaerobic pathways, respectively, for their glucose metabolism.

Effects of depletion of T cell subpopulations on the course of infection and anti-parasite delayed type hypersensitivity response in mice infected with Babesia microti and Babesia rodhaini.

To elucidate the role of T cell subpopulations in the protective cell-mediated immune response at the initial phase of infection with Babesia microti (BM) and B. rodhaini (BR), the changes in the course of infection and anti-parasite delayed type hypersensitivity (DTH) response after BM or BR inoculation were investigated in Lyt-2+ T cell or L3T4+ T cell-depleted mice. Depletion of Lyt-2+ T cells strongly enhanced the resistance to BM infection, whereas it increased the susceptibility to BR infection. In contrast, depletion of L3T4+ T cells increased susceptibility to BM infection, while it enhanced resistance to BR infection. The anti-parasite DTH response in BM-infected mice was significantly enhanced by depletion of Lyt-2+ T cells, while significantly reduced by depletion of L3T4+ T cells. No effects of depletion of either Lyt-2+ or L3T4+ cells on DTH response was observed in BR-infected mice. From these results, it was suggested that the roles of Lyt-2+ and L3T4+ T cells in the protective cell-mediated immune response at the initial phase of infection were different between BM- and BR-infected mice, resulting in the difference in their course of infection.

A short term in vitro cultivation of Babesia rodhaini and Babesia microti.

In vitro cultivation of Babesia rodhaini (BR) and Babesia microti (BM) was attempted. When RPMI1640 was supplemented with 30 or 40% of non-treated fetal bovine serum (FBS), the gas mixture of 3% CO2-8% O2 best supported the growth of both parasites. Under this optimized condition, the percent parasitized erythrocytes peaked to approximately 4- and 2-times initial values for Br and BM, respectively. The cultivated parasites retained the infectivity to the host mice. BM showed the characteristic feature of division during cultivation. However, the lots of FBS will have to be taken into consideration, since the FBS lots were shown to give large varieties to the results. Selection of the appropriate FBS lot may yield the better growth of these protozoa.

Long term follow-up of a 46,XY phenotypic girl with 17alpha-hydroxylase deficiency treated with alternate-day dexamethasone.

We report an 18-year-old 46,XY phenotypic girl who has been on alternate-day dexamethasone therapy for 10 years. The patient was seen at our hospital for right-sided inguinal hernia at the age of 4 years. Biopsy of the herniated gonad showed testicular tissue, and the karyotype of the peripheral lymphocytes was 46,XY. The diagnosis of 17alpha-hydroxylase deficiency was established by the evaluation of adrenal steroidogenesis at the age of 6.1 years when hypertension was clearly recognized, and was confirmed later by the gene analysis of CYP17 which disclosed a compound heterozygote. The growth rate was suppressed during the initial treatment with daily administration of 0.25-0.5 mg dexamethasone. Switching to alternate-day regimen of dexamethasone 0.5 mg/dose improved height velocity. Subsequent addition of low-dose estrogen therapy induced pubertal growth spurt. The blood pressure and adrenal hormone levels remained almost within the normal range throughout the course. Adrenal function was evaluated at the age of 15 years. Plasma ACTH and corticosterone levels were high only just before the next administration, when the plasma dexamethasone concentration should be at the nadir. Since corticosterone possesses glucocorticoid activity and can work as a glucocorticoid reserve, it is assumed that this mode of dexamethasone administration can be a safe treatment for this disorder. We conclude that the patient with childhood 17alpha-hydroxylase deficiency can be safely and effectively treated with alternate-day dexamethasone without interfering with linear growth.

Hypoplastic left coronary artery. In association with occlusive intimal thickening of a coronary artery with ectopic ostium and with atresia of the left coronary ostium.

Two cases of hypoplastic coronary artery (HCA) are presented. Case 1, a 13 year old girl, died suddenly during a long distance race. She had HLCA with marked intimal thickening and an ectopic left coronary ostium above the commisure between the non-coronary and left coronary cusp at post mortem examination. The right coronary artery (RCA) was enlarged and also supplied parts of the area normally supplied by the left coronary artery (LCA). Pathological findings revealed a normal RCA and an extremely hypoplastic LCA with occlusive proliferation of the intima and a myocardial infarction of the left ventricle. Case 2, a 6 year old girl, had a history of effort angina. Selective coronary angiography was performed which failed to demonstrate the orifice of the LCA by aortography. However, the hypoplastic LCA was visualized by RCA angiography as a consequence of anomalous collaterals from the atrioventricular branch of the RCA. We postulate that HCA results from various conditions, including stenosis of the coronary artery orifice, an aberrant course between the pulmonary artery and aorta and ectopic positioning of the coronary artery ostium. In addition, HCA may also be associated with occlusive coronary artery abnormalities.

Measurement of instantaneous viscoelastic properties by impedance-frequency curve of the ventricle.

We developed a method for estimating the instantaneous viscoelastic properties of the left ventricle (LV). This impedance-curve method is based on the instantaneous impedance-frequency curve of the left ventricle generated by a rapidly oscillating mechanical impulse applied to the epicardial surface of the heart. The theoretical basis of the method and experimentally obtained instantaneous impedance-frequency curves were examined to evaluate the validity of our basic assumptions. Using these impedance-curve data, we calculated the instantaneous viscoelastic properties of the LV during the cardiac cycle. The impedance curve shows a configuration that is almost the same as the theoretical curve based on the assumption that an RCL (R, resistor; C, capacitor; L, inductor) parallel circuit is the electrical analog for the LV. The impedance curve varied moment by moment during the development of instantaneous LV pressure. The elastic and viscous coefficients, calculated from the impedance curve, increased with increase of LV pressure. We concluded that the impedance-curve method can delineate the instantaneous viscoelastic properties of the ventricle (especially of the ventricular myocardium).

The instantaneous impedance frequency curve of the ventricle with the regional ischemia.

We studied the feasibility of using the impedance frequency curve method (IFM) to detect the myocardial physical heterogeneity of a cross-circulated isolated canine left ventricle with regional ischemia. The curve changed from a single-peak configuration to a double-peak configuration after the LAD coronary flow cessation and returned to the single-peak configuration with the reperfusion of LAD coronary flow. We concluded that IFM can be a useful tool to describe the physical heterogeneity of the ventricular muscle under the regional ischemia.

Dependence of instantaneous transfer function on regional ischemic myocardial volume.

To obtain the instantaneous left ventricular transfer function curve (instantaneous TFC) under conditions of regional ischemia, sinusoidal accelerations ranging from 30 to 150 Hz were applied to a small area of the epicardium of cross-circulated isovolumic canine left ventricle, and the contralateral acceleration was measured under control and during regional coronary occlusion (n = 11). The TFC is the ratio of the output to input acceleration amplitudes. The instantaneous TFC was characterized as a single-peaked configuration under control coronary perfusion. However, TFCs progressively changed from a single-peaked to a double-peaked configuration during regional ischemia. To quantify this change in instantaneous TFC, we defined an index D as the mean squared difference of TFC during ischemia from TFC during control. Index D was linearly related to the percent mass of the ischemic region at 40 minutes after onset of ischemia. We conclude that 1) transfer function curves are sensitive measures of myocardial heterogeneity and 2) the fractional ischemic weight of the ventricle is a major factor in determination of the deformation in instantaneous TFC at the later stages of regional ischemia.

Gallium-67 myocardial imaging for the detection of myocarditis in the acute phase of Kawasaki disease (mucocutaneous lymph node syndrome): the usefulness of single photon emission computed tomography.

Myocardial imaging with gallium-67 citrate was used to detect myocarditis in 46 consecutive infants and children (31 boys and 15 girls, mean age 21 months) with Kawasaki disease. In all of them planar imaging (group A) was performed at 6 hours and at 48 or 72 hours after the intravenous administration of a mean (SD) dose of gallium-67 citrate (0.07 (0.02) mCi/kg). Thirty four patients (24 boys and 10 girls, mean age 21 months) also had single photon emission computed tomography imaging (group B) soon after planar imaging. The patients had been ill for from 5 days to 16 days (mean (SD) 10.5 (2.4) days in group A and 10.6 (3.0) days in group B). The colour images obtained at 48 or 72 hours were positive in 41% of group A and in 64% of group B. Among the patients with clinically suspected myocarditis, 63% in group A and 80% in group B had positive myocardial images. Single photon emission computed tomography imaging permitted the identification of tracer in the myocardium, the pericardium only, or in the heart chambers. Myocardial imaging with gallium-67 citrate, especially when used with single photon emission computed tomography imaging, is useful for the detection of myocarditis in the acute phase of Kawasaki disease.

The acoustic characteristics of the left ventricle.

A new method was developed to describe the instantaneous resonance curve (IRC) of the left ventricle (LV), which represents the acoustic characteristics and instantaneous viscoelastic properties of LV. This method was evaluated using coronary-perfused isolated canine LV preparations.

Assessment of the magnitude of aortic regurgitation by dye injection into the descending aorta.

A technique simpler than the angiographic method for estimating aortic regurgitant volume was tried with 31 patients with aortic insufficiency. During cardiac catheterization, we injected dye into the descending aorta while recording the dye dilution curve in the left ear. The distance between the aortic arch and the tip of the catheter at the lowest point from which the injected dye could be detected in the left ear was rated in terms of the number of corresponding vertebral bodies. This "distance score" closely correlated with the regurgitant stroke volume and with the fraction to total stroke volume, which were measured by angiocardiography (r = 0.927, p less than 0.001; and r = 0.900, p less than 0.001, respectively). The correlation coefficients of the aortographic grade to those parameters were not as high as they were in the relationship of the score to the same parameters. Therefore, these results indicate that the "distance score" is a practical method for assessing the magnitude of aortic regurgitant volume.

Vibration analysis of the human left ventricular posterobasal wall at the moment of the first heart sound emission.

We examined whether human left ventricular (LV) wall vibration at the first heart sound emission (LVvibr) could be a potential source of information about the left ventricular physical properties, as has been demonstrated by experimental forced vibration studies. LV posterobasal wall vibration in 51 subjects characterized by functional murmur (n = 13), mitral stenosis (n = 8), hypertrophic cardiomyopathy (HCM, n = 8), ischemic heart disease with old myocardial infarction (n = 12) and without prior infarction (n = 10), was detected with a miniature intraesophageal vibration sensor. Peak frequency, sharpness and peak power of LVvibr in patients with functional murmur and mitral stenosis were linearly related to the Q-vibration interval. HCM patients showed a higher peak frequency and sharper configuration in the power spectrum. However, differing from previous reports, we found no characteristic difference in configuration of power spectrum in patients with ischemic heart disease. These results suggest that human LVvibr possibly includes information demonstrated by experimental forced vibration analysis.

The degree of increment in plasma catecholamines in patients with mitral stenosis by mild exercise.

Although sympathetic excitation during mild exercise may readily occur in patients with mitral stenosis (MS), the degree of increment in plasma catecholamines has not been fully investigated. We imposed mild ergometric exercise (50 watts, 300 kg/min for 5 minutes) on five patients with mild MS (mitral valve area greater than or equal to 1.0 cm2) and eight with severe MS (mitral valve area less than 1.0 cm2) while they were undergoing cardiac catheterization. In patients with severe MS, total plasma catecholamine levels during exercise were remarkably higher (2821 +/- 783 [SEM] pg/ml) than in those with mild MS (957 +/- 113 pg/ml, p less than 0.05) and in seven control subjects (612 +/- 75 pg/ml, p less than 0.05). This marked increment could not be predicted by heart rate response, which did not differ between severe and mild MS (166 +/- 5 vs 153 +/- 10 bpm). In contrast with catecholamine change, the cardiac index in severe MS showed a very small increment. Results suggest that mild daily exercise can remarkably increase plasma catecholamine levels in severe MS, and this may accelerate various complications of this disorder.

Radionuclide imaging for assessment of myocarditis and postmyocarditic state in infant and children. Thallium-201 myocardial imaging and technetium-99m-HSA gated equilibrium ventriculography.

T1-201 myocardial imaging and Tc-99m-HSA gated equilibrium ventriculography were performed in 1 infant and 11 children between 2 months old and 12 years old with myocarditis. The time of first evaluation was between 1 week and 13 months after the onset. Their clinical manifestations were congestive heart failure in 2 patients, pericardial effusion in 2 patients, syncope in 1 patient, convulsions in 1 patient and palpitations in 7 patients. Significant elevation of virus antibody titer was demonstrated in 6 patients. A perfusion defect was observed with T1-201 imaging in 9 of 12 patients with myocarditis. A right ventricular image was observed in 5 patients. A reduced LVEF was present in 4 patients and a reduced RVEF was found in 2 patients. Cardiac catheterization was performed in 8 patients and an endomyocardial biopsy was done in 7. The myocardial specimens revealed postmyocarditic pathological changes upon microscopic evaluation. No coronary artery obstructive or stenotic lesions were observed in these patients. T1-201 myocardial imaging is a useful non-invasive technique for evaluating the cardiac performance and myocardial damage in acute myocarditis and the postmyocarditic state. We conclude that T1-201 uptake of myocardium is dependent upon both regional coronary perfusion and the activity of myocardial cells in patients with myocarditis and in the postmyocarditic state.

The left ventricular vibration mode in the ventricular transfer function method and at the moment of the first heart sound.

Several investigators have aimed to clarify the patient's left ventricular (LV) physical properties by free vibration analysis of heart sound. Recently we have developed a transfer function (TF) method to calculate the LV viscoelasticity. To clarify whether this TF method and a clinical first heart sound (1 HS) analysis are based on the identical ventricular vibration mode analysis, we examined (1) the visualized LV vibration image in the TF method and (2) the quantitative relationship between the peak frequency of the 1 HS spectrum and that of TF curve in the early and late phase of the 1 HS. Isolated isovolumic potassium arrested canine left ventricles were used to visualize the vibration mode in describing the TF (N = 2). Examination of stroboscopically illuminated, slow-motion images revealed the oscillation of the ventricle to be of mode 2 behavior. To analyze the quantitative relation between the TF method and 1 HS analysis we used ten open-chest dogs. The correlation was good (r = 0.917) when the peak frequency of the TF curve at the early phase of the 1 HS was compared to the peak frequency of the 1 HS. We concluded that both the TF method and 1 HS analysis were based on the common, second-order ventricular vibration mode. Therefore, some information on the ventricular physical properties suggeted by the TF method could also be included in the clinical data obtained by 1 HS analysis.

[Short- and long-term effects of the new oral prostacyclin analogue, beraprost sodium, in patients with severe pulmonary hypertension].

Prostacyclin (PGI2) is a bioactive substance produced by vascular endothelial cells, which exerts powerful vasodilative and anti-platelet actions. Patients with pulmonary hypertension have an imbalance between vasodilative PGI2 and vasoconstrictive thromboxane B2 (TXB2). Treatment with vasodilative agents is essential for such patients. Continuous intravenous infusion of PGI2 is an effective treatment of primary pulmonary hypertension in terms of exercise capacity and survival rate. We tested a new stable PGI2 analogue, beraprost sodium (Procyclin, Dornar) suitable for oral administration, in patients with primary and secondary pulmonary hypertension. A short-term study of cardiac catheterization in four patients with primary pulmonary hypertension showed a 15 +/- 12% reduction in mean pulmonary artery pressure in three of the four patients, and a 24 +/- 22% decrease in pulmonary vascular resistance in all four patients. Cardiac index increased by 27 +/- 14% in three of the four patients. Among three patients with secondary pulmonary hypertension, there was a 7% reduction in pulmonary artery pressure in one patient, and a 24 +/- 14% decrease in pulmonary vascular resistance in all three patients. In a long-term study (23 +/- 11 months), NYHA functional class improved from 3.0 +/- 0.7 to 2.4 +/- 0.5 in two of the five patients with primary pulmonary hypertension. Although the radiographic cardiothoracic ratio was not significantly improved, cardiac index increased by 78 +/- 60% in four of the five patients. Only two patients, one with primary and one with secondary pulmonary hypertension, died during the long-term follow-up period. Plasma TXB2/6-keto prostaglandin F1 alpha ratio decreased from 8.1 +/- 8.7 to 1.5 +/- 0.4. The optimal dose remains uncertain, but the initial dosage of 40-60 micrograms/day given in three to four doses for adult patients is considered to be acceptable. Side effects such as flushing face, headache, vomiting, and nausea were mild and resolved when the dose was reduced. Oral PGI2, beraprost, appears to be an effective and possibly adequate substitute for intravenous vasodilators in pulmonary hypertension for both short- and long-term management.

Endomyocardial biopsy findings in pediatric patients with post myocarditic state.

Endomyocardial biopsy was performed on eight children 5 to 12 years old, who were in post myocarditic state. They were evaluated within 2 to 25 months (mean lyr and 1 m) after the onset of the symptoms. Two of the patients developed heart failure and six patients developed other cardiac manifestations such as syncope, palpitation or ECG abnormalities at onset. Definite elevation of viral antibody titer was observed in four patients. Radionuclide angiography was also performed in all eight patients. An abnormal perfusion area was observed in six patients as a focal hypoperfusion area by T1-201 myocardial imaging. Ejection fraction was examined by Tc-99m-HSA gated equilibrium ventriculography. LVEF was reduced in 3 patients and RVEF was reduced in 2 patients. Judging from the histopathological findings, these patients were divided into three categories: chronic or smoldering myocarditis (3 patients); healing or healed myocarditis (4 patients); and post myocarditic hypertrophy (1 patient). Measurement of left ventricular function was obtained by cardiac catheterization and left ventriculography (LVG), which revealed some abnormal findings such as increased left ventricular mass index, increased left ventricular end diastolic volume index (LVEDVI) and reduced left ventricular ejection fraction (LVEF). Therefore, endomyocardial biopsy findings of pediatric patients in a post myocarditic state reveal certain histopathological abnormalities even in the long-term follow-up period in the absence of cardiac dysfunction.