A case of Goodpasture syndrome positive for anti-GBM antibody and MPO-ANCA complicated by a variety of serious infections.

A 62-year-old female was admitted to our hospital for investigation of acute progressive renal insufficiency and a systemic inflammatory reaction, despite treatment with several antibiotics. Laboratory data revealed severe renal insufficiency and positive titers for the myeloperoxidase anti-neutrophil cytoplasmic and anti-glomerular basement membrane antibodies. The deterioration of her general status did not allow us to perform the renal biopsy. Although corticosteroid therapy, hemodialysis, and plasma exchange were concomitantly initiated, pulmonary hemorrhage occurred several days after admission. Mechanical ventilation support was provided and continuous hemodiafiltration was carried out, following which the respiratory failure improved immediately. However, she developed clinical depression and suicidal behavior under the intensive therapy. Therefore, plasma exchange was discontinued and corticosteroid was tapered as quickly as possible. Four months after admission, platelet transfusion and short-term mechanical ventilation support improved the pulmonary hemorrhage; however, her mental status deteriorated despite psychiatric consultation and treatment with a tranquilizer. Thereafter, severe and serious systemic infection due to various pathogens including Staphylococcus aureus, Cytomegalovirus, Pneumocystis jiroveci, Pseudomonas aeruginosa, and Bacteroides recurred, and she died from systemic invasive aspergillosis (IA). We suspected severe immunosuppression caused by various factors, such as predonisolone administration, chronic renal failure on maintenance hemodialysis, depression, and malnutrition due to chronic inflammation and granulocytopenia as a side effect of ganciclovir. When treating rapidly progressive glomerulonephritis, immunosuppressive status should be carefully monitored regarding not only the dosage of therapeutic regimen but also the mental health status and nutrition of the patient.

Crescentic glomerulonephritis associated with totally implantable central venous catheter-related Staphylococcus epidermidis infection.

A 59-year-old woman was admitted to our hospital for treatment of acute renal insufficiency. She had been under home intravenous hyperalimentation therapy through a totally implantable central venous catheter for 2 years because of post-radiation enteritis. Clinical examination on admission revealed severe renal insufficiency complicated with hypocomplementemia, marked proteinuria and hematuria. Chest roentgenography demonstrated moderate pulmonary congestion. Hemodialysis was initiated and her pulmonary congestion improved. On the 14th and 21st hospital day, blood culture revealed Staphylococcus epidermidis colonization. Cefazolin was administered and C-reactive protein decreased, however, renal insufficiency and hypocomplementemia did not improve. To investigate the genesis of renal insufficiency, renal biopsy was performed. Light microscopic findings of the kidney revealed severe crescentic glomerulonephritis complicated with moderate tubulointerstitial damage. Immunofluorescence-microscopic findings of the kidney revealed positive IgG, IgM, C3 deposition along the capillary lumen. From these laboratory findings and the clinical course, we diagnosed her renal disease as crescentic glomerulonephritis induced by catheter-related bloodstream infection, and the central venous catheter was removed. After removal, urinary output and hypocomplementemia remarkably improved, however, unfortunately, her renal dysfunction did not improve and maintenance hemodialysis needed to be continued. Although her renal disease was not caused by ventriculo-atrial shunt but by central venous catheter-related bloodstream infection, we supposed that the pathogenesis was a closely similar entity to shunt nephritis.

Idiopathic nodular glomerulosclerosis: three Japanese cases and review of the literature.

Idiopathic nodular glomerulosclerosis (ING) is characterized as diffuse nodular glomerulosclerotic lesions, closely resembling Kimmelstiel-Wilson lesions without diabetic mellitus. We report here three Japanese cases of ING and discuss the previous reports. The patients were 75-, 48- and 84-year-old males with a history of long-term hypertension. Laboratory examination revealed moderate proteinuria and mild renal dysfunction. Diabetes mellitus was excluded by repeated clinical and laboratory investigations. Renal histology revealed nodular glomerulosclerosis, and both afferent and efferent arteriolosclerosis in all patients. In electron microscopy, the glomerular basement membrane was markedly thick in all patients. A low-protein diet and potent anti-hypertensive treatment using angiotensin-converting enzyme inhibitors were initiated in all patients and urinary protein excretion significantly reduced without the progression of renal dysfunction. We reviewed 42 previously reported cases and our three cases. The analysis revealed that common clinical features of ING are being male (82.2%) of relatively advanced age (mean age 61.3 years), with hypertension (82.2%), mild renal dysfunction (mean serum creatinine 2.9 mg/dl) and moderate urinary protein excretion (mean 4.05 g/day). Common histopathological findings of ING are nodular glomerulosclerosis (100%), arterio-arteriolosclerosis (91.2 and 89.7%) and glomerular basement membrane thickening (85.7%). In conclusion, ING is one of the phenotypes of arteriosclerotic renal disease without diabetes mellitus. Severe arterio-arteriolosclerosis may contribute to the progression to glomerular nodular formation in ING. The combination of renin-angiotensin system inhibition and a low protein diet can be beneficial for the reduction of urinary protein excretion.

Renal involvement in cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL).

Cerebral autosomal dominant arteriopathy with subcortical infarcts and leukoencephalopathy (CADASIL) is a hereditary systemic arteriopathy presenting with migraines, mood disorders, focal neurologic deficits, recurrent ischemic attacks and dementia in young adults. The genesis of this disease relates to missense mutation of the Notch3 gene. We report here a newly identified CADASIL patient and discuss unique vascular lesions observed in the kidney. A 64-year-old female was admitted to our hospital for the investigation of proteinuria, hematuria and progressive neurological abnormalities. Her mother and brother died of cerebral infarction at a relatively young age despite a lack of apparent risk factors for arteriosclerosis. Over the past 4 months before admission, she had suffered from frequent transient ischemic attacks despite appropriate antiplatelet therapy. Blood examination revealed mild renal insufficiency and urinalysis revealed moderate protein excretion and dysmorphic hematuria. Magnetic resonance imaging of the brain revealed multiple infarcts and leukoencephalopathy. Histopathological analysis of the kidney revealed focal segmental mesangial proliferation, the loss and degeneration of arterial medial smooth muscle cells and arterial intimal thickening. Immunofluorescence analysis of glomeruli revealed IgA deposition in the mesangial area. Electron microscope analysis revealed electron-dense deposition also in the mesangial area. In addition, granular osmophilic material (GOM) was observed in the extraglomerular mesangial area and around the vascular smooth muscle cells. Genetic analysis of Notch3 revealed an R141C missense mutation and she was diagnosed with CADASIL complicated with IgA nephropathy. In immunohistological analysis, Notch3 stains were positive in vascular smooth muscle cells of the interlobular arteries and both afferent and efferent arterioles, and weak in the glomerular mesangial area. Antihypertensive treatment using angiotensin II receptor blocker and a low protein diet were initiated, and her urinary protein excretion decreased to 0.2 g/day. However, due to the progression of her neurological abnormalities, she became socially withdrawn. In CADASIL, GOM, abnormal accumulation of Notch3 ectodomain, is thought to induce the degeneration and loss of vascular smooth muscle cells and subsequent intimal thickening. Analysis of our cases provided that these morphological abnormalities were also observed in the CADASIL patient kidney.

Histological analysis on adhesive molecules of renal intravascular large B cell lymphoma treated with CHOP chemotherapy and rituximab.

A 48-year-old man was admitted to our hospital for investigation of mild renal dysfunction. A blood examination revealed mild elevation of creatinine level (1.77 mg/dl). Urinary examination revealed mild protein excretion (0.54 g/day) and microhematuria; renal biopsy revealed the focal proliferation of large mononuclear cells with mitosis in glomerular capillaries. According to immunohistochemical analysis, the intravascular lymphomatous cells stained positively with anti-leukocyte common antigen (LCA: CD45) and CD20, indicating a B lymphocyte lineage. In electron microscopy, the glomerular capillary was filled with lymphoma cells and epithelial foot process fusion was noted. Immunohistochemical analysis on adhesive molecules revealed a lack of CD11a expression on lymphoma cells, but positive CD54 expression on endothelial cells. Systemic 18F-fluorodeoxyglucose positron emission tomography (FDG-PET) revealed no abnormal uptake of isotopes. On the basis of these findings, we diagnosed intravascular diffuse large B cell lymphoma localized in the kidney. Despite treatment with rituximab and CHOP (prednisolone, doxorubicin, vincristine, cyclophosphamide) for 3 cycles at 1-month intervals, the renal dysfunction did not change. In histopathological analysis of the second biopsy, lymphoma cells disappeared, but focal segmental glomerulosclerosis and moderate interstitial fibrosis were noted. Electron microscopic findings revealed severe subendothelial edema with mesangial interposition, indicating severe endothelial damage. Epithelial foot process fusion was improved. These pathological analyses let us conclude that a lack of CD11a could be a candidate factor for prevention of the extravasation of lymphoma cells from blood vessels in our patient. We also presumed that the intraglomerular endothelial damage occurred due to chemotherapy-associated cell injury.

Expression of p-STAT3 in human colorectal adenocarcinoma and adenoma; correlation with clinicopathological factors.

BACKGROUND: The signal transducer and activator of transcription 3 (STAT3) is a key signalling molecule implicated in the regulation of growth and malignant transformation. Constitutive activation of STAT3 is seen in several tumour derived cell lines, and in a wide variety of human malignancies. AIMS: To examine the relation between p-STAT3 (activated form of STAT3) expression and clinicopathological factors in human colorectal adenocarcinoma and adenoma. METHODS: Immunohistochemical analyses were carried out on tissues from 44 colorectal adenomas and 95 colorectal adenocarcinomas, comprising 18 intramucosal carcinomas and 77 invasive carcinomas. RESULTS: Seventy seven of these 139 samples (55.4%) showed immunoreactivity for p-STAT3. Positive staining for p-STAT3 was seen in 69 of the 95 carcinomas. Only eight of the 44 adenomas showed immunopositivity for p-STAT3, resulting in a significant difference between total adenocarcinomas and adenomas (p < 0.001). Among the 95 cases of colorectal adenocarcinoma, p-STAT3 immunoreactivity was significantly correlated with the depth of tumour invasion (p < 0.05), venous invasion (p < 0.05), lymph node metastasis (p < 0.05), and increasing stages of the Dukes' classification (p < 0.01). Expression of p-STAT3 was detected by Western blot analysis in two different cultured human colorectal carcinoma cell lines and six colon carcinoma tissue samples obtained at surgery. CONCLUSION: This is the first study to report a significant correlation of p-STAT3 expression with the depth of tumour invasion. These findings suggest that p-STAT3 expression is an important factor related to carcinogenesis and/or tumour invasion of colorectal adenocarcinoma.

A combination chemoendocrine therapy of mitoxantrone, doxifluridine, and medroxyprogesterone acetate for anthracycline-resistant advanced breast cancer.

Between January 1993 and October 1995, 34 patients with anthracycline-resistant advanced breast cancer were treated with a combination chemoendocrine therapy of mitoxantrone (MIT), doxifluridine (5'-DFUR) and medroxyprogesterone acetate (MPA). Of 34 patients, 28 were evaluable for efficacy of this combination therapy, and 30 including 2 for whom data were incomplete were assessed for adverse drug reactions. Adriamycin (ADM) was used for pretreatment in 12 patients, 4'-epi-ADM in 6, and THP-ADM in 12. In the eligible patients, 8.0 mg/m2 MIT was administered intravenously every 4 weeks, and 600 mg MPA and 600 mg 5'-DFUR were given orally every day. The median follow-up period was 25 weeks (range 2-90 weeks). The median cumulative dose of mitoxantrone was 66 mg (range 12-121 mg). Of the 28 patients, 11 (39.3%) responded to this combination therapy. As for response in relation to predominant site of lesion, 1 of 5 soft tissue lesions (20%) and 8 of 12 bone metastases (66.7%) showed a partial response, and one complete response and one partial response (25.0%) were seen in eight lung lesions. None of three pleural lesions responded to this therapy. The median duration of response was 31 +/- weeks (range 12-82 weeks). Adverse drug reactions were controllable or tolerable. Combined chemoendocrine therapy with a low dose of MIT is a well-tolerated and moderately effective regimen for the treatment of anthracycline-resistant advanced breast cancer.

Immunohistochemical demonstration of alpha-fetoprotein in small hepatocellular carcinoma.

We demonstrated immunohistochemical staining of a-fetoprotein (AFP) in small hepatocellular carcinoma (HCC). Fifty-six patients with HCC less than 2 cm in diameter were studied. Twenty-five HCCs (44.6%) were positive for AFP-staining. The positive rate of AFP-staining in HCC tissue was higher in the patients with serum AFP concentration above 20 ng/ml than that of the patients with below 20 ng/ml. AFP-staining was demonstrated on the rough endoplasmic reticulum of HCC cells by immuno-electron microscopy. AFP-staining of tissue specimens obtained by fine needle biopsy is useful in the histologic diagnosis of HCC.

Effects of 5'-DFUR and OK-432 on cytokines and thymidine phosphorylase in tumor tissue of gastric cancer patients.

BACKGROUND: The purpose of the study was to verify whether OK-432 in combination with 5'-DFUR induced thymidine phosphorylase (TdR Pase) and cytokines in gastric cancer patients as well as in vitro. MATERIALS AND METHODS: Fifty patients with invasive gastric cancer were randomly assigned, upon admission using by a closed-envelope technique, to either a group receiving 5'DFUR or OK-432 alone, to a group receiving both 5'DFUR and OK-432, or to a non- treated group up. Surgical specimens of the tumor and normal tissues were taken soon after gastrectomy to evaluate TdR Pase activity, IL-1 alpha and TNF-production. RESULTS: TdR Pase activities were several times higher in tumor than in normal tissues. In normal tissues, TdR Pase activities in the 5'-DFUR + OK-432 group were significantly higher than in the OK-432 group. TdR Pase activity in tumors, however, showed no significant difference between treated group. In the 5'-DFUR + OK-432 group, the level of IL-1 alpha production in tumor was significantly higher compared to the control group. In the 5'-DFUR + OK-432 group, the level of TNF alpha production in tumor was significantly higher than in normal tissue. TNF alpha production in tumor showed no significant difference in each treated group compared to the control. There was a significant correlation between TdR Pase activity and IL-1 alpha production levels in tumor. CONCLUSIONS: TdR Pase was induced by IL-1 alpha in tumor tissues of gastric cancer patients. OK-432 in combination with 5'-DFUR, however, did not induce TNF alpha and IL-1 alpha, and increase TdR Pase activity in gastric cancer tumors.

Case report: nifedipine-rifampicin interaction attenuates the effect on blood pressure in a patient with essential hypertension.

A 72-year-old woman with 5-year history of essential hypertension developed peritoneal tuberculosis. The patient's hypertension, which had been well-controlled by long-acting nifedipine, deteriorated after the administration of rifampicin, an antitubercular agent. During use of nifedipine and rifampicin, both the peak plasma concentration and the area under the curve of nifedipine decreased markedly to about 40% of those without rifampicin. The findings suggest that rifampicin may increase the elimination of nifedipine, presumably by induction of its hepatic metabolism. Nisoldipine, another calcium antagonist, also failed to lower the patient's blood pressure, when given in combination with rifampicin. Taken together, these findings indicate that more caution should be urged when calcium antagonist is prescribed along with rifampicin.

Occult Boerhaave's syndrome without vomiting prior to presentation. Report of a case.

Boerhaave's syndrome (spontaneous esophageal perforation) is an uncommon clinical entity that frequently presents with an antecedent history of marked vomiting followed by chest or abdominal pain. We report a case of spontaneous rupture of the esophagus in 53-year-old male who was referred to our hospital with a chest discomfort. A chest radiogram revealed pleural effusion and pneumomediastinum. Nine hours after onset, the diagnosis of Boerhaave's syndrome become evident. She underwent operative repair and, after a prolonged stay, was discharged in relatively good condition 55 days after admission. The absence of vomiting prior to presentation is the distinguishing feature of this particular case. This is the seventh case in the English literature to our knowledge.

Intraoperative radiotherapy and bypass surgery for unresectable pancreatic cancer.

BACKGROUND/AIMS: Conflicting results have been reported concerning the usefulness of radiotherapy for unresectable pancreatic cancer. We evaluated the clinical efficacy of intraoperative radiotherapy and/or external beam radiotherapy in combination with bypass surgery. METHODOLOGY: Twenty-six patients with unresectable pancreatic cancer (16 in Stage II-III and 10 in Stage IV) were treated with intraoperative radiotherapy plus external beam radiotherapy (16 patients) or intraoperative radiotherapy alone (10 patients). The dose of intraoperative radiotherapy was either 25 or 30 Gy and the external beam radiotherapy dose was 31-60 Gy. The feasibility and clinical outcome were analyzed. RESULTS: The median survival time for Stage II-III and Stage IV were 11.5 and 6.5 months, respectively. The difference between Stage II-III and Stage IV in survival patterns was statistically significant (P < 0.05). For Stage II-III patients, the survival curves between the groups of intraoperative radiotherapy plus external beam radiotherapy and intraoperative radiotherapy alone were not significantly different, and only performance status was a significant factor in the prognosis (P < 0.05). Gastrointestinal bleeding was noted in 8%, but did not occur in the patients treated with an external beam radiotherapy dose less than 50 Gy. Palliative radiation was successfully performed to relieve pain, jaundice and appetite-loss and to shorten the hospital stay. CONCLUSIONS: The combination therapy with intraoperative radiotherapy and bypass surgery is considered to be tolerable and effective for unresectable pancreatic cancer, and also may improve the quality of life of the patients.

Relationship between Lens culinaris agglutinin reactive alpha-fetoprotein and biological features of hepatocellular carcinoma.

Lens culinaris agglutinin-reactive fraction of alpha-fetoprotein (AFP-L3), which is a fucosylated variation of AFP, is not only sensitive and specific for localization of hepatocellular carcinoma (HCC) but also a prognostic factor for patients with HCC. The relationship between status of AFP-L3% in serum and pathological findings was studied using 48 resected HCC specimens. AFP-L3 fraction was measured by lectin-affinity blotting using an AFP Differentiation Kit L (Wako, Osaka, Japan), and was expressed as AFP-L3% (AFP-L3/total AFP x 100%). A cut-off level of 15% was used. Pathological findings of HCC such as histological grade (well, moderately and poorly differentiated HCC), vascular invasion, and Ki67 (MIB1), p53 (DO7) and alpha-catenin immunohistochemical staining were studied. According to the results of serum AFP concentrations and AFP-L3%, the 48 patients were divided into the following three groups: AFP greater than or equal to 20 ng/ml and AFP-L3 positive (group A, n = 14), AFP greater than or equal to 20 ng/ml and AFP-L3 negative (group B, n = 14) and AFP less than 20 ng/ml (group C, n = 20). Ki67 labeling index of HCC tissue in group A was 27.8 +/- 18.9%, which was significantly higher than those of group B (9.6 +/- 10.1%, p < 0.024) and group C (11.1 +/- 11.2%, p < 0.03). In group A, p53 expression was higher and alpha-catenin staining was reduced significantly compared with those of group B or C, respectively. The results of the study suggest that the proportion of AFP-L3% in serum reflects some biological features of HCC.

[Clinical study of an outbreak of aseptic meningitis due to echovirus type 30 in Munakata City in 1997-1998].

From October, 1997 through July, 1998, an outbreak of aseptic meningitis due to echovirus type 30 occurred in the northern part of Kyushu area in Japan. In this outbreak, clinical and virologic observations were carried out on 157 in-patients with aseptic meningitis at our hospital. The age of the patients ranged from 1 year and 9 months to 57-year old. One hundred and twenty out of 157 cases were the children under 15 years of age, and in this age group, male/female ratio was 2:1. The largest proportion of cases occurred in the 5- to 9-year age group. The number of cases reached a peak in December, 1997, but the epidemic extended to the next summer. In 12 families, more than one person became ill (total 22 cases). Virus isolation from cerebrospinal fluid (CSF) was tried on 130 out of 157 cases. Echovirus 30 was isolated in 74 cases (58 children, 16 adults), and echovirus 18 in 9 cases from June, 1998 until the end of the study. Paired acute and convalescent sera were available from the 25 patients with negative virus isolation, and 7 out of 25 patients had a fourfold or greater rise in neutralizing antibodies. Headache, fever, vomiting, nuchal rigidity were detectable in most cases, but in this outbreak, continued severe headache was characteristic. Eye pain was experienced by 2% of the total cases. In children, gastrointestinal symptoms were noted in 12% of the cases, but were not in adult patients. The CSF cell counts ranged from 2 to 3,478 cells per cubic millimeter. Fifty-eight percent were predominantly lymphocytic, while 42% were polymorphonuclear predominant. Virus was highly isolated from the CSF when the specimens were obtained within three days after the onset of the acute illness, but in one case, virus was isolated on day 7. In a few cases, virus was isolated without pleocytosis in CSF.

[Herpes zoster in connective tissue diseases: I. Association with systemic lupus erythematosus and its immunological abnormalities].

We determined the incidence of herpes zoster (HZ) in 119 patients with systemic lupus erythematosus (SLE). HZ occurred in 56 patients (47%), and 9 patients had had HZ even before SLE developed. After diagnosis of SLE, an incidence of zoster was high, 5.45 cases per 100 person-years. It was found that the susceptibility to HZ was not related to the presence of renal disorder or maximum dose of corticosteroids. The patients with SLE who had had HZ showed significantly higher antibody titers than those without a history of HZ and normal subjects as assayed by both complement fixation technique and neutralization test. On the other had, only 17 of 55 patients (31%) with SLE showed positive skin reactions to varicella zoster virus (VZV) antigen, whereas all 15 normal subjects had positive reactions. In the patients who were receiving less than 10 mg/day of prednisolone, 11 of 17 (65%) had positive skin reactions to VZV antigen, whereas only 4 of 31 (13%) patients who were receiving 10 mg/day or more prednisolone showed positive reactions. It was of interest that in 7 patients with SLE who had not received corticosteroids, only 2 (29%) patients showed positive skin reactions to VZV antigen. These results suggest that high incidence of HZ in patients with SLE is probably due to an impaired cellular immunity because of both underlying disease and corticosteroid treatment.

[Herpes zoster in connective tissue diseases: II. Rheumatoid arthritis and mixed connective tissue disease in comparison with systemic lupus erythematosus].

We investigated the incidence of herpes zoster (HZ) and the immunological state to HZ in patients with rheumatoid arthritis (RA) and mixed connective tissue disease (MCTD) in comparison with systemic lupus erythematosus (SLE). HZ occurred in 6 (25%) out of 24 patients with RA and 4 (22%) out of 18 patients with MCTD. One patient had had HZ before the diagnosis of RA. On the other hand, all 4 patients with MCTD had had HZ before the diagnosis of MCTD. The patients with RA and MCTD showed normal or higher antibody titers to varicella zoster virus (VZV) than normal subjects as assayed by both complement fixation technique and neutralization test. However, the antibody levels were not very high compared to those in patients with SLE. On the other hand, only 7 (50%) of 14 patients with RA and 4 (40%) of 10 patients with MCTD showed positive skin reactions to VZV antigen, whereas all 15 normal subjects had positive reactions. Thus, cellular immunity to VZV was thought to be impaired in these diseases. In the patients who were receiving less than 10 mg/day of prednisolone, 7 (64%) of 11 had positive skin reactions in RA patients and 3 (60%) out of 5 patients with MCTD, whereas none (0%) out of 3 patients with RA and 1 (20%) out of 5 patients with MCTD who were receiving 10 mg/day or more prednisolone showed positive skin reactions. These results suggest that the high incidence of HZ in patients with RA and MCTD is probably due to an impaired cellular immunity as in the case of SLE.

Distribution of tyrosine hydroxylase (TH)-like, neuropeptide Y (NPY)-like immunoreactive and acetylcholinesterase (AChE)-positive nerve fibers in the prostate gland of the monkey (Macacus fuscatus).

Nerve fibers containing immunoreactivities for tyrosine hydroxylase (TH) and neuropeptide Y (NPY), and exhibiting acetylcholinesterase (AChE) reactivity were examined by means of histochemical and immunohistochemical methods in the caudal lobe of the prostate in the monkey, Macacus fuscatus. TH-like immunoreactive nerve fibers were distributed abundantly in the interstitium where smooth muscle fiber bundles were rich and scarcely in the paraurethral region where they were rare. NPY-like immunoreactive nerve fibers, less abundant than TH-like immunoreactive nerve fibers, were observed not only in the interstitium but also around the prostatic acini. AChE-positive nerve fibers were much denser around the acini than in the interstitium. Both the NPY-like immunoreactive and the AChE-positive nerve fibers showed an intimate spatial association with the epithelium of the acini. Judging from the distribution pattern of these nerve fibers, the following assumption is possible. Secretion of the prostatic gland as well as the outflow of the prostatic fluid into the urethra induced by contraction of the smooth muscle cells in the interstitium may be controlled by sympathetic adrenergic nerves, while cellular secretion of the acinar epithelium is regulated by parasympathetic cholinergic nerves. The NPY-like immunoreactive nerve fibers around the acini may be non-noradrenergic; they may regulate the cellular secretion by acting on the cholinergic nerves as well as by having a direct effect on the acinar secretory cells.

Inflammatory pseudotumor of the liver--MR imaging findings.

Using retrospective studies, we have investigated the possibility of obtaining characteristic findings of inflammatory pseudotumor of the liver by magnetic resonance (MR) imaging. We examined 8 patients (involving 8 masses) who had been histologically diagnosed as having an inflammatory pseudotumor in the liver. The histological studies were performed on an excised specimen of 1 mass, and on aspiration needle biopsy specimens and the clinical courses of the other 7 masses. T1 weighted images (T1WI) and T2 weighted images (T2WI) were obtained on MR imaging. MR imagings were analyzed for visualized patterns, patterns of internal structure and patterns of contrast enhancement of dynamic MR imaging. The 8 masses were visualized as hypointense on T1WI and hyperintense on T2WI by MR imaging. Dynamic MR imaging revealed that 1 mass was markedly enhanced peripherally while another mass was homogeneously enhanced, and that enhancement was most marked immediately after injection of contrast medium and then gradually disappeared. Vessels were observed in 4 masses (the portal vein in 2 masses, the hepatic vein in 1 mass, and portal and hepatic veins in 1 mass), and these vessels were clearly visualized on T1WI. The MR imaging findings from the early stage of an inflammatory pseudotumor showed a pattern similar to that of hepatic tumors with rich blood flow. The portal vein or hepatic vein was found in the tumor in half the patients, suggesting that this characteristic was useful for diagnosis of an inflammatory pseudotumor in the liver.

[Clinical studies on the transference of cephem-type antibiotics into bile and gallbladder tissues with special reference to cefotiam and cefmenoxime].

Cefotiam (CTM) and cefmenoxime (CMX) were studied for their serum concentrations and transference into bile in patients with PTCD or T-tube. One gram of CTM or either 1 g or 2 g of CMX was administered by an intravenous drip infusion for over 30 minutes. These drugs were also studied for their serum concentrations, bile concentrations, and tissue concentrations in the walls of the gallbladder of patients operated on for cholelithiasis. Intravenous drip infusion (over 30 minutes) was used to administer 1 g of CTM or 1 g or 2 g CMX immediately before surgery. Both CTM and CMX were readily transferred into bile. Their bile concentrations, however, varied greatly among patients, and extremely low levels were detected in some patients. A crossover analysis of concentrations of CMX in bile of patients given doses of 1 g and 2 g revealed a dose-response relationship. The crossover analysis of drug concentrations in bile of patients given CTM and CMX showed that CMX is transferred more readily to bile. The relationship between liver functions and drug transfer to bile was examined by plotting the total bilirubin level against drug concentrations in bile. The plots formed an exponential curve with a correlation coefficient (r) being -0.52 in cases when each subjects received 1 g of CTM and -0.72 in cases when each subjects received 1 g of CMX. A study of 3 patients given CMX at a dose of 1 g suggested that bile levels of CMX may be correlated to ICG. Concentrations of CTM and CMX in tissues of the gallbladder wall were fairly high, with unexpectedly small variance among patients. Even in patients with low bile concentrations of these drugs, drug levels in the tissues of the gallbladder wall were high. Drug levels in the noninflammatory tissues were higher than those in inflammatory lesions. The above findings suggest that CTM should be the antibiotic of choice for patients with ordinary biliary tract infections and after the surgery of the liver and biliary tract system, while CMX should be the antibiotic of choice for patients with severe biliary tract infections, and for compromised hosts after the surgery of the liver and biliary tract system.

Spontaneous rupture of renal angiomyolipoma.

We report a case of renal angiomyolipoma with retroperitoneal hemorrhage treated by enucleation in a 47 year-old male. The mass in the anterior side of the left kidney, revealed by sonography and CT, was diagnosed as angiomyolipoma with a retroperitoneal hematoma caused by its spontaneous rupture. Removal of hematoma and enucleation of the tumor were performed after the diagnosis. Diagnosis and treatment of ruptured renal angiomyolipoma are discussed.