A case of familial lecithin-cholesterol acyltransferase deficiency on hemodialysis for over 20 years.

We trace the 34-year history of a member of the first Japanese family in which lecithin-cholesterol acyltransferase (LCAT) deficiency was diagnosed. Marriage between cousins with low LCAT activity was responsible for familial LCAT deficiency (FLD). In 1976, a 27-year-old Japanese man was noted to have FLD based on proteinuria, hematuria, grayish corneal opacity and low LCAT activity (9.83%). Genetic analysis showed insertion of G-G-C coding glycine at codon 141. Total cholesterol (C) was low at 108 mg/dl and the ratio of C-ester to total C was very low (12%), while the lecithin (phosphatidylcholine) level was very high (97.3%). When his serum creatinine reached 2.6 mg/dl at the age of 41 years (in 1991), renal biopsy was performed. This showed expansion of the mesangial matrix and irregularly thickened capillary walls with a bubble-like appearance because of lipid deposits consisting of two components (partly lucent vacuolated areas and partly deeply osmiophilic areas). Magnification of the latter deposits showed curvilinear and serpiginous striated membranous structure. Hemodialysis was started in 1990 and has been continued for over 20 years until August 2010. Clinical problems have included AV shunt failure requiring 4 operations and 13 percutaneous transcatheter angioplasty procedures, as well as episodes of hemolytic anemia that subsided after infusion of fresh frozen plasma. Cardiovascular events have not yet occurred, although severe calcification of abdominal aorta has been detected by computed tomography.

Hepatitis C virus-related kidney disease: various histological patterns.

BACKGROUND: Although hepatitis C virus (HCV) infection is known to be associated with Type 2 cryoglobulinemic glomerulopathy (CG), only a few reports about other types of nephropathy have been published. METHODS: 68 HCV antibody positive patients in whom renal biopsy had been performed for persistent proteinuria, hematuria, and/or renal dysfunction between 1992 and 2008 at our institute were included. The histological, clinical and laboratory characteristics including the age, gender, hypertension, diabetes mellitus, liver histology (chronic hepatitis or liver cirrhosis), HCV-RNA, HCV genotype, splenomegaly, gastroesophageal varices, serum creatinine, hemoglobin, platelet count, rheumatoid factor, cryoglobulin, IgG, IgA, IgM, CH50, C3, C4, creatinine clearance, 24-h protein excretion, and hematuria, between their nephropathy with and without immune deposition were compared. RESULTS: Nephropathy was classified into two groups based on the detection of immune deposits by immunofluorescence microscopy: i.e., a positive group (n = 39) and a negative group (n = 29). The former group was further classified into three types of nephropathy: IgG dominant group (n = 10) (including membranous nephropathy (MN)), IgA dominant group (n = 20) (including IgA nephropathy (IgAN)), membranoproliferative glomerulonephritis (MPGN) (IgA type)), and IgM dominant group (n = 9) (MPGN apart from the IgA type). The latter group included diabetic nephropathy (n = 13), focal glomerular sclerosis (n = 4), and benign nephrosclerosis (n = 3), malignant nephrosclerosis (n = 1), tubulointerstitial nephritis (TIN) (n = 2), minimal change nephrotic syndrome (n = 1), cast nephropathy (n = 1), granulomatous TIN (n = 1), and others (n = 3). An increased serum IgM level, hypocomplementemia, splenomegaly, thrombocytopenia, liver cirrhosis, hematuria, and a high HCV RNA level were features of patients with MPGN of IgM dominant group (consistent with "CG"). CONCLUSIONS: Our results showed various histological patterns of HCV-related kidney disease and the specificity of CG, and revealed that a minority of HCV patients (n = 7) presented typical CG, while IgAN, MN, and diabetic nephropathy were more frequent.

Distribution of tritiated tetrodotoxin administered intraperitoneally to pufferfish.

Tetrodotoxin was recoil-tritiated by the 3He(n,p)3H reaction and purified by gel filtration. The [3H]tetrodotoxin gave only one spot in both cellulose acetate strip electrophoresis and thin layer chromatography. The specific toxicity of tetrodotoxin did not decrease during the recoil tritiation and the [3H]tetrodotoxin showed a specific radioactivity of 25 x 10(-6) Ci/mmole. In spite of the low specific radioactivity, the [3H]tetrodotoxin was able to be used to investigate the anatomical distribution of tetrodotoxin in pufferfish. When intraperitoneally injected into 'torafugu' puffer, [3H]tetrodotoxin accumulated in most tissues, the level being highest in the skin, followed by the liver, intestines and muscle. With time, the [3H]tetrodotoxin radioactivity level in the injected pufferfish decreased in most tissues, except for skin and gallbladder. Based on these results, the metabolism of tetrodotoxin in pufferfish is discussed.

Disseminated cryptococcosis presenting with adrenal insufficiency and meningitis: resistant to prolonged antifungal therapy but responding to bilateral adrenalectomy.

A case of disseminated cryptococcosis with features of primary adrenal insufficiency and meningitis in an immunocompetent host is presented. Despite antifungal chemotherapy, neither meningitis nor bilateral adrenal gland enlargement was improved. Aspiration biopsy of the adrenal gland revealed necrotic tissue with numerous fungi, suggesting that the adrenal glands were the focus of the persistent fungemia. Removal of bilateral adrenal glands led to improvement by making the patient more sensitive to antifungal chemotherapy.

[Muscle sympathetic nerve activity (MSNA) in a patient with tetanus].

Autonomic nervous function was studied in a 57-year-old female patient with tetanus of mild degree, by recording muscle sympathetic nerve activity (MSNA) using the microneurographic method, as well as by measuring blood pressure, heart rate and plasma content of norepinephrine (NE). No apparent clinical signs of autonomic dysfunction were observed. Recording of MSNA on the 7th hospital day revealed decreased discharge rates compared with age-matched healthy subjects, indicating suppressed sympathetic nerve function. The decreased MSNA returned to closely normal level after 3 months, when the clinical symptoms and signs were almost completely cleared up. Previous studies have shown facilitated sympathetic nerve function, while some sympathetic nerves remain suppressed, and therefore unstable cardiovascular dysfunction might be elicited in tetanus.

[Laboratory and clinical studies on cefoperazone in pediatrics treatment (author's transl)].

Laboratory and clinical studies of cefoperazone (CPZ), a new semisynthetic cephalosporin, were investigated and following results were obtained. (1) Blood level: CPZ was given intravenous dose of 25 mg/kg and 50 mg/kg to each 3 children. In the former, the blood level of 15 minutes after injection was 194.2 mcg/ml on average and the half life was 106.2 minutes. In the latter, the blood level was 320.0 mcg/ml on average and half life was 102.2 minutes. (2) Urinary concentration: In the cases of the dose of 25 mg/kg, 35.9% of CPZ was recovered on average from the urine within 6 hours after injection, and the urinary concentration reached to 2,148.6 mcg/ml (0 approximately 2 hours). And in the cases of the dose of 50 mcg/kg, the recovery rate in urine was 43.6%, and the urinary concentration was 3,008.3 mcg/ml. (3) Cerebrospinal fluid level: CSF level was determined in a patient with bacterial meningitis by S. pneumoniae. Ninety mg/kg of CPZ were given intravenous injection. After 60 minutes CSF level was 3.35 mcg/ml, and after 80 minutes the blood level was 192.0 mcg/ml. (4) Bacteriological evaluation: Against 164 strains isolated clinical specimens, the bacteriological evaluation on CPZ was performed in comparison with cefotaxime (CTX), cefazolin (CEZ) and piperacillin (PIPC) by inoculum size of 10(8) cells/ml. CPZ showed antibacterial activity against Gram-negative bacteria almost similar to CTX and PIPC. (5) CLINICAL RESULTS: CPZ was given 48.3 approximately 360 mg/kg/day (average 146.1 mg/kg/day) by intravenous route to 46 patients with various infection. The overall efficacy rate was 80.4%. The rate of bacteriological effectiveness was 78.9% in 19 cases. (6) Side effects: As side effects, diarrhea, fever, rash, urticaria, leukopenia, eosinophilia, elevation of GOT, GPT, and LDH were observed, but not seriously.

[Inflammatory cell infiltration around beta 2-microglobulin amyloid deposition: histologic comparison of beta 2-microglobulin amyloidosis with AA or AL amyloidosis].

Thirty-one autopsy cases of beta 2-microglobulin (beta 2M) amyloidosis were pathologically investigated in comparison with 17 autopsy cases of AA or AL amyloidosis. In 20 cases (65%, 20/31) of beta 2M amyloidosis, inflammatory cells, mainly macrophages were seen infiltrating around beta 2M amyloid in intervertebral disks. The more beta 2M amyloidosis advances, the more macrophage infiltration tends to be prominent. In cases of severe beta 2M amyloidosis, the cytoplasm of macrophages around amyloid deposition were swollen with engulfed amyloid substance and were often transforming to foreign body multinucleated giant cells. In addition, granulation tissue was formed with infiltrating macrophages, foreign body multinucleated giant cells, capillary proliferation and fibrosis around beta 2M amyloid deposition. On the other hand, inflammatory cell infiltration around amyloid deposition was scarcely seen in AA or AL amyloidosis. Ultrastructurally, macrophages were abundant in phagocytic vacuoles containing amyloid fibrils. These macrophages were immunohistochemically positive for CD68, IL-1 beta and TNF-alpha. Thus, macrophage infiltration around beta 2M amyloid is thought to be responsible for local pain and tissue destruction of dialysis patients.

[Phase I-II study of hepatic intraarterial one-shot administration of adriamycin in patients with metastatic liver cancer].

For the purpose of obtaining the optimal dose of adriamycin (ADM) in hepatic intraarterial one-shot administration, phase I-II study was conducted in 14 patients with various liver cancers. The starting dose of ADM was 20 mg/m2 (4 patients) and the doses were escalated to 40 mg/m2 (5 patients), 60 mg/m2 (4 patients) and 80 mg/m2 (3 patients). One patient with salivary gland cancer showed PR for the liver metastasis. Major toxicity was leukopenia. With a dose of 40 mg/m2, 3 out of 4 patients showed nadir of WBC counts below 4,000/mm3 (2,400, 2,900, 3,100), 60 mg/m2 (1,100, 1,500, 2,200 and 2,700), and 80 mg/m2 (900, 1,200, and 1,400). Nadirs of WBC counts were observed from 9 to 15 days after the one-shot administration, and recovered above 4,000/mm3 in 1 to 3 weeks. Plasma concentrations of ADM from the peripheral vein were determined by HPLC in 12 patients, 14 courses. The curves of ADM plasma levels after 20 and 40 mg/m2 bolus injections were almost the same, and in patients treated with 60 and 80 mg/m2 the curves were also quite similar, but higher in the plasma levels, comparing with in patients with 20 and 40 mg/m2. There might be a limit of ADM tissue absorption, and above the doses 60 mg/m2, ADM might be overflowed, followed by side effects, especially leukopenia. Upon these data of venous plasma concentrations of ADM and leukopenia, the optimal dose of ADM in the hepatic intraarterial one-shot administration seemed to be 40 mg/m2.

Moderator effects on recoil tritium reactions with lithium beta-phenylpropionate.

The recoil tritium reactions were studied with lithium beta-phenylpropionate having both the aromatic and aliphatic C-H bonds in the molecule, mainly in terms of the moderator effect on the intramolecular tritium distribution. Recoil tritium atoms were produced by the 6Li(n,alpha)3H reaction. Water molecules were used as the moderator. The tritium activity of the ethylene group represented relative to that of the corresponding ring assumed as a standard (= 100) is 30 in the moderator-free system and is reduced to 13 in the moderated system in which the H2O/beta-PhC2H4CO2Li mole ratio is 328. In the ring, the tritium distribution shows a slight ortho- and para-orientation in the moderator-free system and the selectivity is pronounced when the H2O/beta-PhC2H4CO2Li mole ratio is large. The data show that the aromatic ring tritiation in the moderated system is given by increasing contribution of the reactions of tritium atoms having lower energy than the threshold energy of the ethylene group tritiation.

The reactions of recoil tritium atoms with toluene in the C6F6-moderated systems.

The T-for-H substitution reaction was studied in the recoil tritium reactions with toluene in C6F6-moderated systems. The moderator-free control experiment showed an approximately uniform labeling in the aromatic ring, with a slightly enhanced reactivity in the ortho- and para-positions (o: 41%, m: 38%, p: 21%) and showed a preference for ring tritiation over methyl group tritiation (23 relative to the corresponding ring assumed as a standard (= 100)). The addition of hexafluorobenzene progressively changed the uniform distribution to a marked ortho- and para-orientation and decreased the relative tritium activity of the methyl group. If the C6F6/PhCH3 mole ratio is 204, the tritium distribution in the ring is o: 53%, m: 22%, p: 25% and the methyl group activity is reduced to 2. The data show the existence of the threshold energy of side chain tritiation and that the selective aromatic ring tritiation is given by increasing contribution of the reactions of tritium atoms having lower energy than the threshold energy.

Reactions of recoil tritium atoms with toluene and benzonitrile.

Recoil tritium reactions in the aromatic ring were investigated with toluene and benzonitrile in the moderator-free and the C6F6-moderated systems in terms of the intramolecular tritium distribution, the relative tritiation rate, and the isotope effect in toluene. The reactions free from hexafluorobenzene are in essential agreement with non-selective nature shown in hot atom reactions. The addition of the moderator to the systems changes more markedly the uniform labeling to o,p-orientation in toluene than in benzonitrile, and the 1.17 PhCH3/PhCN tritiation rate (in PhCH3-d8/PhCN, 0.942) to the 1.89 PhCH3/PhCN one (in PhCH3-d8/PhCN, 1.51) when the mole ratio of C6F6/substrate is about 100. These findings agree with the electrophilic nature of the tritium at lower energies. The H/D isotope effect in the moderated system is given as 1.89/1.51 or 1.25 and is substantially the same as that (1.24) in the moderator-free system.

Intraductal ultrasonography of the pancreas: development and clinical potential.

Intraductal ultrasound (IDUS) probes mounted with 30 MHz or 20 MHz transducers were evaluated in the diagnosis of 239 patients with pancreatic disease (including 48 cancers, 90 mucin-producing tumors, seven islet-cell tumors, two metastatic pancreatic tumors, seven serous cystadenomas, one pancreatic teratoma, three solid cystic tumors, 49 cases of chronic pancreatitis, 25 cases of focal pancreatitis, and seven cases of pancreatolithiasis). The probe was inserted via the papilla into the main pancreatic duct. In terms of resolution, IDUS at 20 MHz was able to image cystic lesions of less than 30 mm in diameter and solid lesions of less than 20 mm in diameter. With regard to vessels, IDUS was able to image the entire cross-section of the portal vein and other large veins. IDUS was useful in detecting carcinoma in situ and small tumors, in assessing the intraductal spread of the tumor and its pancreatic parenchymal invasion in mucin-producing tumors of the main duct, and in assessing the indications for surgery by revealing mural nodules in mucin-producing tumors of the ductal branches. IDUS was also useful in evaluating the feasibility of partial resection of the tumor in mucin-producing tumors of the ductal branches and pancreatic islet-cell tumors, in accurately locating multiple lesions in pancreatic islet-cell cancer, and in differentiating benign from malignant cases of localized stenosis of the main pancreatic duct related to pancreatic stenting. With IDUS, the site of pancreatic stones could be identified in order to assess the need for endoscopic treatments such as stenting of the pancreatic duct and the bile duct, and the use of pulsed-dye laser treatment under pancreatoscopy for pancreatic stones. Acute pancreatitis as a complication occurred in one of the 239 patients who underwent IDUS (0.4%). An awareness of the limitations and usefulness of IDUS in evaluating pancreatic diseases can contribute to the treatment of these conditions.