The ridge line of left pulmonary vein isolation from left atrial appendage can subsequently increase the completion rate of the mitral isthmus block line.

BACKGROUND AND OBJECTIVES: Mitral isthmus (MI) ablation for mitral flutter is technically difficult, and incomplete block line is not uncommon. The objective of this study is to investigate the effect of the ridge line of left pulmonary vein isolation (LPVI) from left atrial appendage (LAA) on completion rate of mitral isthmus (MI) block line and recurrence rate of atrial tachycardia (AT) or atrial flutter (AFL) after the first MI ablation. METHODS: We identified 611 patients who underwent first MI ablation for mitral flutter during the study period. Finally, 559 patients were enrolled and divided into two groups according to the method of ridge line ablation of LPVI (LAA group, n = 467, conventional group, n = 92). Outcome measures were the completion of MI block line by first MI ablation, the recurrence of AT/AFL, and repeat MI ablation after the first MI ablation. RESULTS: The first MI block line completion rate was significantly higher in the LAA group than the conventional group (95% vs. 85%, p < 0.001). The recurrence rate of AT/AFL after 3 months from first MI ablation was significantly lower in the LAA group. The requirement of additional MI ablation tended to be lower in the LAA group. CONCLUSIONS: Our novel approach of ablating LPV-LAA ridge from the LAA side during PVI can increase the success rate of MI block line completion, and reduce the recurrence rate of AT/AFL and the need for additional MI block line ablation. Graphical abstract Ablation of the left pulmonary vein-left atrial appendage ridge from the left atrial appendage side during PVI increased the success rate of mitral isthmus block line completion.

Associations between hemodynamic parameters at rest and exercise capacity in patients with implantable left ventricular assist devices.

BACKGROUND: Hemodynamic parameters at rest are known to correlate poorly with peak oxygen uptake (VO2) in heart failure. However, we hypothesized that hemodynamic parameters at rest could predict exercise capacity in patients with left ventricular assist device (LVAD), because LVAD pump rotational speed does not respond during exercise. Therefore, we investigated the relationships between hemodynamic parameters at rest (measured with right heart catheterization) and exercise capacity (measured with cardiopulmonary exercise testing) in patients with implantable LVAD. METHODS: We performed a retrospective medical record review of patients who received implantable LVAD at our institution from November 2013 to December 2017. RESULTS: A total of 20 patients were enrolled in this study (15 males; mean age, 45.8 years; median duration of LVAD support, 356 days). The mean peak VO2 and cardiac index (CI) were 13.5 mL/kg/min and 2.6 L/min/m2, respectively. CI and hemoglobin level were significantly associated with peak VO2 (CI: r = 0.632, p = 0.003; hemoglobin: r = 0.520, p = 0.019). In addition, pulmonary capillary wedge pressure, right atrial pressure, and right ventricular stroke work index were also significantly associated with peak VO2. In multiple linear regression analysis, CI and hemoglobin level remained independent predictors of peak VO2 (CI: ß = 0.559, p = 0.006; hemoglobin: ß = 0.414, p = 0.049). CONCLUSIONS: CI at rest and hemoglobin level are associated with poor exercise capacity in patients with LVAD.

Pathological changes of the myocardium in reworsening of anthracycline-induced cardiomyopathy after explant of a left ventricular assist device.

We herein report the long-term changes in cardiac function and pathological findings after successful explantation of a left ventricular assist device in a 42-year-old patient with anthracycline-induced cardiomyopathy with reworsening heart failure. Endomyocardial biopsy samples revealed that the cardiomyocyte diameter decreased and collagen volume fraction increased just after left ventricular assist device explantation. The collagen volume fraction decreased after 6 months, despite preserved systolic function. At 5 years after left ventricular assist device explantation, the systolic function markedly decreased and cardiomyocyte diameter increased. Pathological changes of the myocardium may enable the identification of cardiac dysfunction prior to echocardiographic changes in patients with reworsening heart failure after left ventricular assist device explantation.

Pulmonary artery pressure may be a predictor of closed aortic valve in patients managed by venoarterial extracorporeal membrane oxygenation.

In the management of venoarterial extracorporeal membrane oxygenation, some patients present persistently closed aortic valve. However, little is known about the variables that contribute to persistently closed aortic valve. We investigated the factors that could predict persistently closed aortic valve at the time of venoarterial extracorporeal membrane oxygenation initiation. We investigated 17 patients who presented closed aortic valve immediately after the introduction of venoarterial extracorporeal membrane oxygenation. Patients who presented closed aortic valve 24 h after introduction of venoarterial extracorporeal membrane oxygenation were defined as the Closed-AV group (n = 8), while those whose aortic valve remained opened after 24 h were defined as the Open-AV group (n = 9). All patients were managed by concomitant use of intra-aortic balloon pumping. At baseline, there were no significant differences between mean arterial blood pressure, central venous pressure, and left ventricular ejection fraction. However, Closed-AV group had significantly lower mean pulmonary artery pressure and pulmonary artery pulse pressure compared to those of Open-AV group (mean pulmonary artery pressure: 15 ± 6 mmHg vs 25 ± 8 mmHg, p = 0.01; pulmonary artery pulse pressure: 3 ± 2 mmHg vs 8 ± 3 mmHg, p < 0.01). Logistic regression analyses revealed that the lower mean pulmonary artery pressure and pulmonary artery pulse pressure had the predictive value of closed aortic valve within 24 h after venoarterial extracorporeal membrane oxygenation initiation (mean pulmonary artery pressure: odds ratio = 0.78, 95% confidence interval = 0.58-0.95, p < 0.01; pulmonary artery pulse pressure: odds ratio = 0.18, 95% confidence interval = 0.01-0.61, p < 0.01). Lower mean pulmonary artery pressure and pulmonary artery pulse pressure values could predict persistent closed aortic valve 24 h after venoarterial extracorporeal membrane oxygenation initiation. Left ventricular preload derived from right heart function may have a major impact on aortic valve status.

Giant cell myocarditis with central diabetes insipidus: A case report.

A 51-year-old male, previously diagnosed with central diabetes insipidus due to lymphocytic hypophysitis, presented with fever and dyspnea for 1 week. On arrival, he exhibited hypotension (85/60 mmHg) and sinus tachycardia (110 bpm). His electrocardiogram revealed mild ST elevation on V2-V4. Echocardiography indicated a near-normal (50%) left ventricular ejection fraction (LVEF), although the inferior wall of the left ventricle exhibited severe hypokinesis. Fulminant myocarditis and circulatory insufficiency were suspected, and treatment with dobutamine, 3 µg/kg/min, was started. His LVEF gradually decreased to 20%. On day 17, he developed cardiogenic shock due to ventricular tachycardia and underwent peripheral venous-arterial extracorporeal membrane oxygenation and intra-aortic balloon pumping. Although he did not exhibit polyuria, intravenous vasopressin infusion (0.5 U/h) was performed to maintain normonatremia. Endomyocardial biopsy results revealed the infiltration of scattered giant cells (GCs) and extensive lymphocytes. Despite immunosuppressive therapy (methylprednisolone and cyclosporine), his cardiac function did not recover. On day 36, he received a biventricular assist device; however, he died on day 47 due to the progression of sepsis and multiple organ failure. We speculate that a deficient expression of programmed cell death protein-1 was the cause of both GC myocarditis and lymphocytic hypophysitis. .

Potential prognostic implications of myocardial thallium-201 and iodine-123-beta-methylpentadecanoic acid dual scintigraphy in patients with Anderson-Fabry disease.

OBJECTIVES: Information on the relationship between myocardial damage assessed by myocardial scintigraphy and prognosis in patients with Anderson-Fabry disease (AFD) is lacking. We therefore aimed to investigate the prognostic impacts of myocardial thallium-201 (201Tl) and iodine-123 beta-methyl 15-para-iodophenyl 3(R, S)-methylpentadecanoic acid (123I-BMIPP) dual scintigraphy in patients with AFD. METHODS: Eighteen consecutive patients with AFD underwent resting myocardial 201Tl/123I-BMIPP dual scintigraphy. Total defect scores (TDS) on both images were calculated visually according to the 17-segment model using a 5-point scoring system. The mismatch score (MS) was calculated as 'TDS on 123I-BMIPP-TDS on 201Tl'. RESULTS: Six major adverse cardiac events (MACEs) were recorded during a mean follow-up of 6.7 ± 4.2 years (three heart failure requiring hospitalization and three cardiac deaths). Left ventricular mass index, left atrial diameter, brain natriuretic peptide, TDS on 123I-BMIPP, and MS were all significantly greater in patients with MACEs compared with those without. Kaplan-Meier analysis indicated that high TDS on 123I-BMIPP and high MS were associated with poor event-free survival. CONCLUSION: TDS on 123I-BMIPP was a better prognostic determinant in patients with AFD than TDS on 201Tl. Myocardial 201Tl/123I-BMIPP dual scintigraphy may thus be a useful noninvasive modality for evaluating prognosis in patients with AFD.

Early Blood Pressure Reduction by Intravenous Vasodilators Is Associated With Acute Kidney Injury in Patients With Hypertensive Acute Decompensated Heart.

BACKGROUND: Intravenous vasodilators are commonly used in patients with hypertensive acute decompensated heart failure (ADHF), but little is known about their optimal use in blood pressure (BP) management to avoid acute kidney injury (AKI). The purpose of this study was to investigate the association between systolic BP (SBP) changes and the incidence of AKI in patients with hypertensive ADHF.Methods and Results:Post-hoc analysis was performed on a prospectively enrolled cohort. We investigated 245 patients with ADHF and SBP >140 mmHg on arrival (mean age, 76 years; 40% female). We defined "SBP-fall" as the maximum percent reduction in SBP 6 h after intravenous treatment. AKI was defined as serum creatinine (SCr) ≥0.3 mg/dL, or urine output <0.5 mL/kg/h (n=66) at 48 h. Mean SBP and SCr levels on arrival were 180 mmHg and 1.21 mg/dL, respectively. Patients with AKI had significantly larger SBP-fall than the others (36.7±15.3% vs. 27.2±15.3%, P<0.0001). Logistic regression analysis showed an odds ratio per 10% SBP-fall for AKI of 1.49 (95% confidence interval 1.29-1.90, P=0.001). SBP-fall was significantly associated with the number of concomitant used intravenous vasodilators (P=0.001). The administration of carperitide was also independently associated with increased incidence of AKI. CONCLUSIONS: Larger SBP-fall from excessive vasodilator use is associated with increased incidence of AKI in patients with hypertensive ADHF.

Prognostic impact of mitral L-wave in patients with hypertrophic cardiomyopathy without risk factors for sudden cardiac death.

Hypertrophic cardiomyopathy (HCM) with severe diastolic dysfunction is a major cause of heart failure and sudden cardiac death (SCD) associated with lethal arrhythmia. Although various risk factors for cardiac events have been reported in HCM patients, previous studies have reported that some HCM patients exhibit either no risk or a low risk of SCD experienced cardiac events. The mid-diastolic transmitral flow velocity curve (mitral L-wave) is an echocardiographic index of left ventricular compliance, and it has been reported as one of the parameters of advanced diastolic dysfunction assessed noninvasively. However, little is known about the association between the mitral L-wave and long-term clinical outcomes in HCM patients without SCD risk factors. Between July 2005 and February 2016, 112 patients were diagnosed with HCM and 96 patients without risk factors were enrolled. After excluding 3 patients whom we could not detect L-wave more than once, 93 patients (mean age 57.7 ± 13.1 years, 33 females) were divided into the following two groups, according to the presence or absence of the mitral L-wave: Group L (+) (with the mitral L-wave) and Group L (-) (without the mitral L-wave). The correlations between the mitral L-wave and rates of cardiac events were investigated. The mitral L-wave was present in 14 (15.1%) patients [Group L]. During the follow-up period [4.7 (2.9-7.5) years], patients experienced 7 cardiac events. Kaplan-Meier survival analysis showed that the event-free rate was significantly lower in Group L (+) than in Group L (-) (log-rank P = 0.002). Additionally, in multivariate analysis, L-wave positivity was identified as independent predictors of cardiac events. Existence of the mitral L-wave can predict cardiac events, even in HCM patients without SCD risk factors.

A survival case of a young adult patient with ST-elevated myocardial infarction with high levels of lipoprotein(a).

A 23-year-old Japanese man presented to a nearby hospital with a complaint of chest pain. In terms of the risk factors for cardiovascular events, there were no abnormal findings in past medical examinations and no smoking history. The 12-lead　electrocardiogram revealed ST-elevation in V1-V6, I, and aVL, and he was diagnosed with acute myocardial infarction. Emergency coronary angiography findings revealed total occlusion of the left main trunk and collateral vessels from the right coronary artery to the left anterior descending artery. He underwent emergency percutaneous coronary intervention and placement of drug-eluting stent under the support of venoarterial-extracorporeal membrane oxygenator (VA-ECMO). On day 8 after the onset, transthoracic echocardiography revealed that cardiac function improved with left ventricular ejection fraction from 10% to 20% and VA-ECMO was successfully removed. Alternatively, laboratory findings revealed abnormally high levels of serum lipoprotein(a) [Lp(a), 74 mg/dL] despite the normal levels of low-density lipoprotein cholesterol, high-density lipoprotein cholesterol, and triglyceride. In addition, computed tomography angiography revealed atherosclerosis and stenosis of internal and external carotid arteries, subclavian artery, and renal artery. The abnormally high levels of serum Lp(a) could influence systemic atherosclerosis as well as the onset of myocardial infarction in our young adult patient. .

Left Ventricular Relaxation Half-Time as a Predictor of Cardiac Events in Idiopathic Dilated Cardiomyopathy and Hypertrophic Cardiomyopathy With Left Ventricular Systolic and/or Diastolic Dysfunction.

PURPOSE: Diastolic dysfunction preceding systolic dysfunction is considered an important interaction in cardiomyopathy with poor prognosis. The aim of this study was to compare left ventricular (LV) isovolumic relaxation with the other parameters as a potential prognostic marker for patients with idiopathic dilated cardiomyopathy (IDC) and hypertrophic cardiomyopathy (HC). METHODS: A total of 145 patients with IDC and 116 with HC were evaluated for hemodynamic parameters; LV pressure was directly measured by a micromanometer catheter, and relaxation half-time (T1/2) was used to determine LV isovolumic relaxation. The median follow-up period was 4.7 years. RESULTS: The mean ages of the patients with IDC and HC were 52.0 ± 12.0 and 57.1 ± 12.4 years, respectively. Each patient group was further divided into 2 groups based on the median value of T1/2: (1) <41.0 ms (D-L group) and ≥41.0 ms (D-H group) (2) <38.5 ms (H-L group) and ≥38.5 ms (H-H group). Kaplan-Meier analysis showed a significantly higher probability of cardiac events in the D-H group than in the D-L group (p = 0.001) and in the H-H group than in the H-L group (p = 0.028). Further, Cox proportional hazard regression analysis revealed that T1/2 was an independent predictor of cardiac events for patients with IDC (hazard ratio 1.109; p = 0.007) and HC (hazard ratio 1.062; p = 0.041). In conclusion, regardless of the type of cardiomyopathy, T1/2 as a measure of LV isovolumic relaxation function was found to be associated with the occurrence of cardiac events.

Hemodynamics of cardiac tamponade during extracorporeal membrane oxygenation support in a patient with fulminant myocarditis.

Fulminant myocarditis (FM) causes rapid onset severe heart failure requiring inotropes or mechanical circulatory support. Myocarditis is sometimes associated with pericardial effusion, however, how this effusion affects the hemodynamics in patients with FM under venoarterial extracorporeal membrane oxygenation (VA-ECMO) management has not been fully reported. We show a case of FM presenting with cardiac tamponade during VA-ECMO management. A 64-year-old female diagnosed as having FM showed a rapid hemodynamic collapse and that led to the application of VA-ECMO. Although her left ventricular ejection fraction did not improve despite proper hemodynamics management for several days, a pericardial effusion accumulated gradually. Apparent elevation of right atrial pressure and reduction of blood pressure were not observed, however, we performed pericardiocentesis because we were not able to wean off VA-ECMO. After the drainage of pericardial effusion, the blood pressure and cardiac output elevated as did the left ventricular ejection fraction. We successfully removed VA-ECMO and the patient was discharged without any complications. This is a case report in which a cardiac tamponade under VA-ECMO did not show typical signs and pericardiocentesis contributed to withdrawal of a VA-ECMO system. .

Promising method for management of venoarterial extracorporeal membrane oxygenation: A case of severe heart failure successfully stabilized by "high-flow/vasodilation method".

We report the case of a 58-year-old man with dilated cardiomyopathy who was hospitalized because of worsening heart failure. As his symptoms were refractory even with the administration of inotropes, he was given peripheral venoarterial extracorporeal membrane oxygenation (VA-ECMO) upon transfer to our hospital. On admission, serum creatinine was 2.62 mg/dL and total bilirubin 10.8 mg/dL. The cannulas inserted were 16-Fr for infusion and 21-Fr for drainage. When the blood flow was increased to 2.14 L/min/m2 to improve organ dysfunction, the aortic valve became continuously close with the mean arterial pressure of 85 mmHg. Therefore, we administrated vasodilators to decrease mean arterial pressure, or left ventricular afterload, which achieved opening aortic valve continuously. After the cannula sizes were scaled up to 18Fr for infusion and 24Fr for drainage to gain further blood flow, the aortic valve opened continuously and mean pulmonary pressure decreased. Our strategy to maintain adequate flow rate of VA-ECMO using vasodilator, "high-flow/vasodilation method", achieved hemodynamic stability. Additionally, the concentration of serum creatinine and total bilirubin gradually decreased to within the normal range, although the patient succumbed 58 days after transfer to our hospital. .

Artificial Self-Sufficient Cytochrome P450 Containing Multiple Auxiliary Proteins Demonstrates Improved Monooxygenase Activity.

Most bacterial cytochrome P450 monooxygenases (P450s) do not work alone because their active species is generated by two electrons supplied through two separate auxiliary proteins. Artificial "self-sufficient" P450s, in which one molecule each of the two auxiliary proteins is arranged close to the P450s, have been developed but have not achieved the maximum catalytic turnover numbers of the P450s. In this study, the Pseudomonas putida P450 (P450cam) is assembled with multiple molecules of its auxiliary proteins, putidaredoxin (PdX) and putidaredoxin reductase (PdR), by fusion to a heterotrimeric protein. In the assembled P450cam containing one PdX and one PdR, kinetic analysis reveales that the catalytic cycle of P450cam is suspended twice awaiting the reduction of PdX by PdR. An increase in the number of PdR molecules stimulated the PdX reduction process. Assembly with two PdXs allows one PdX to be reduced during the binding of the other PdX to P450cam for the first electron transfer, eliminating one waiting step. Finally, P450cam assembled with two PdXs and three PdRs showes 92% of the maximum activity of free P450cam. Therefore, assembly with multiple molecules of auxiliary proteins will facilitate in vitro biotechnological applications of the P450s.

Late-Onset Fulminant Myocarditis With Immune Checkpoint Inhibitor Nivolumab.

A 60-year-old man was diagnosed with melanoma. After receiving 13 infusions of nivolumab, he had fulminant myocarditis. The myocardial biopsy specimen revealed extensive lymphocytic infiltration, interstitial edema, and myocardial necrosis, with predominant CD4+, CD8+, CD20-, and programmed death-1- markers. Programmed death-1 ligand 1 (PD-L1) was predominantly expressed on the surface of the damaged myocardium. Although it is reported that myocarditis induced by the human anti-programmed death-1 inhibitor nivolumab therapy rarely occurred at > 2 months use in clinical trials, this case showed that even if at a late phase, long-term use of immune checkpoint inhibitors might to lead immune-related adverse events including myocarditis.

Immobilization of a Bacterial Cytochrome P450 Monooxygenase System on a Solid Support.

Bacterial cytochrome P450s (P450s), which catalyze regio- and stereoselective oxidations of hydrocarbons with high turnover rates, are attractive biocatalysts for fine chemical production. Enzyme immobilization is needed for cost-effective industrial manufacturing. However, immobilization of P450s is difficult because electron-transfer proteins are involved in catalysis and anchoring these can prevent them from functioning as shuttle molecules for carrying electrons. We studied a heterotrimeric protein-mediated co-immobilization of a bacterial P450, and its electron-transfer protein and reductase. Fusion with subunits of a heterotrimeric Sulfolobus solfataricus proliferating cell nuclear antigen (PCNA) enabled immobilization of the three proteins on a solid support. The co-immobilized enzymes catalyzed monooxygenation because the electron-transfer protein fused to PCNA via a single peptide linker retained its electron-transport function.

A case of extensive encircling pulmonary vein isolation in a patient with severe scoliosis.

The patient was a 62-year-old man with atrial fibrillation and severe scoliosis. Scoliosis may impair cardiorespiratory function. Enhanced computed tomography (CT) was helpful for the Brockenbrough method. Three-dimensional (3D) mapping also demonstrated clockwise rotation of the heart. We successfully isolated extensive encircling pulmonary vein in this patient using enhanced CT and 3D mapping. The CT venous images revealed appropriate localization of the vein and heart. CT and 3D mapping may ensure a more stable and safer procedure.

[An autopsy case of penetration of a sigmoid colon diverticulum with septic shock during the treatment of lung cancer-related pain].

A 70-year-old man presented with septic shock and abdominal pain during treatment of pain caused by stage IV lung adenocarcinoma. CT revealed air collection from the retroperitoneum to the muscle around the thigh. Septic shock due to retroperitoneal penetration from the digestive tract was suspected. Despite treatment attempts, the patient died. The autopsy diagnosis was penetration of a sigmoid colon diverticulum under the serosa. When a diverticulum is located near the mesenterium and the size of penetration is small, the air collection rather than fecal matter is likely to extend retroperitoneally. Abdominal pain is little manifest in the penetration in contrast to perforation into abdominal cavity, and the attention is needed.

Fine tuning of spatial arrangement of enzymes in a PCNA-mediated multienzyme complex using a rigid poly-L-proline linker.

Inspired by natural multienzyme complexes, many types of artificial multienzyme complexes have recently been constructed. We previously constructed a self-assembled complex of a bacterial cytochrome P450 and its ferredoxin and ferredoxin reductase partners using heterotrimerization of proliferating cell nuclear antigen (PCNA) from Sulfolobus solfataricus. In this study, we inserted different peptide linkers between ferredoxin and the PCNA subunit, and examined the effect on activity of the self-assembled multienzyme complex. Although the activity was affected by the lengths of both the rigid poly-L-proline-rich linkers and the flexible Gly4-Ser repeating linkers, the poly-L-proline-rich linkers provided the greatest activity enhancement. The optimized poly-L-proline-rich linker enhanced the activity 1.9-fold compared with the GGGGSLVPRGSGGGGS linker used in the previously reported complex, while the Gly4-Ser repeating linkers, (G4S)n (n = 1-6), did not yield higher activity than the maximum activity by the optimized poly-L-proline linker. Both the rigidity/flexibility and length of the peptide linker were found to be important for enhancing the overall activity of the multienzyme complex.

Development of coarse-graining DNA models for single-nucleotide resolution analysis.

Recently, analytical techniques have been developed for detecting single-nucleotide polymorphisms in DNA sequences. Improvements of the sequence identification techniques has attracted much attention in several fields. However, there are many things that have not been clarified about DNA. In the present study, we have developed a coarse-graining DNA model with single-nucleotide resolution, in which potential functions for hydrogen bonds and the pi-stack effect are taken into account. Using Langevin-dynamics simulations, several characteristics of the coarse-grained DNA have been clarified. The validity of the present model has been confirmed, compared with other experimental and computational results. In particular, the melting temperature and persistence length are in good agreement with the experimental results for a wide range of salt concentrations.

[A patient of recurrent orbital myositis with good response to high-dose intravenous immunoglobulin (i.v.-i.g.) therapy].

We report a 62-year old woman with orbital myositis who had a favorable response to intravenous immunoglobulin (i.v.-IG) administration in preventing disease recurrence. She had been suffering from frequent relapses of swelling and redness of the left eye with increasing pain and diplopia caused by restricted eye movement of the left eyeball. T2-weighted magnetic resonance image of the orbit showed enlargement of the left medial rectus muscle. She was treated with 1 g of methylprednisolone per day for 3 days. One mg/kg per day of oral prednisolone was subsequently started with non-steroid anti-inflammatory drugs, which resulted in improvement. However, her symptoms were aggravated while the drug was tapered off even though she used a high dose of oral prednisolone. High dose of i.v.-IG (400 mg/kg per day) was then administered for five days. Since the treatment, she has been free from recurrences of the disease for over one year, suggesting that i.v.-IG can prevent the recurrence of orbital myositis. Some reports have suggested that i.v.-IG treatment is useful to prevent recurrence of other forms of inflammatory myositis, such as dermatomyositis or polymositis. Overproduction of the pro-inflammatory cytokines (IL-1, IL-1 beta, INF-alpha) and Th1 cytokines (INF-gamma, IL-2) are related to the deterioration of these diseases. I.v.-IG treatment suppresses the production of the pro-inflammatory cytokines. In our case, serum levels of the pro-inflammatory cytokines were all normal, but the IL-4 level was elevated after the i.v.-IG treatment, suggesting that orbital myositis was probably related to the Th1 dominant disease that was suppressed by IL-4.