Disseminated toxoplasmosis with atypical symptoms which developed with exacerbation of systemic lupus erythematosus.

Toxoplasma is a common parasite worldwide that mainly affects the brain, lungs and eyes. Although toxoplasmic encephalitis is a lethal disease without treatment, past case reports show most patients with systemic lupus erythematosus who developed toxoplasmic encephalitis were misdiagnosed and treated as neuropsychiatric systemic lupus erythematosus, which led to unfavorable outcomes. We herein describe a case of disseminated toxoplasmosis affecting all the above organs with atypical symptoms, which developed with exacerbation of systemic lupus erythematosus. She had initially manifested with retinochoroiditis without vitritis, mild cognitive impairment and an isolated lung mass. These are completely different from the classic symptoms of toxoplasmosis that have been reported in patients with HIV infection and/or those after hematopoietic transplantation. Our case, together with previously reported cases, suggests the manifestation of toxoplasmosis that develops in systemic lupus erythematosus patients can be different from that seen in conventional cases and varies between individual patients. Our case highlights both the difficulty in and the importance of diagnosing toxoplasmosis in patients with systemic lupus erythematosus and provides helpful information to identify this rare, devastating, yet treatable disease.

Flicker electroretinograms recorded with mydriasis-free RETeval system before and after cataract surgery.

PurposeThe purpose of this study is to compare the amplitudes and peak times of the flicker electroretinograms (ERGs) recorded before and after cataract surgery with the RETeval system (LKC Technologies, Gaithersburg, MD, USA) from eyes without dilation.Patients and methodsThirty-two eyes of 32 patients (77.3±6.5 years) that had grade 2 Emery-Little nuclear or cortical cataract without any other abnormalities were studied. Flicker ERGs were recorded with the RETeval system under mydriatic-free conditions. Skin electrodes were used to pick-up the ERGs that were elicited by white light delivered at a rate of 28.3 Hz and intensity of 2, 8, and 32 Td-s. The amplitudes and peak times of the flicker ERGs before and after cataract surgery were compared.ResultsThe mean amplitudes were significantly increased after the removal of the cataractous lenses at the three stimulus intensities (2 Td-s, P<0.0001; 8 Td-s, P<0.0001; and 32 Td-s, P<0.0001). The mean peak times of the flicker ERGs elicited by 2 and 8 Td-s were significantly shortened after the surgery (2 td-s, P<0.0001 and 8 td-s, P=0.0127) but not at 32 td-s (P=0.595).ConclusionsThese results indicate that the presence of cataracts will affect both the amplitudes and the peak times of the flicker ERGs even if the cataract is mild. In addition, the results indicate that as stimulus intensity increases, the peak times is less affected by a cataract. The clarity of the crystalline lens should be considered when interpreting the flicker ERGs recorded with the RETeval system.

Evaluation of seasonal and daily changes of plasma thyroxine and cortisol levels in wild masu salmon Oncorhynchus masou, sampled by a Japanese fishing method.

A new fish sampling method was developed using a Japanese bait fishing rod (8-9 m carbon rod and a nylon line with a small fine wire single hook), which is considered to catch wild salmonid juveniles with low sampling stress. Using this method, seasonal and daily changes of plasma thyroxine (T4 ) and cortisol levels were examined in wild parr, pre-smolts and smolts of masu salmon Oncorhynchus masou in contiguous locations in a coastal river (Kesen River; 44 km) in northern Honshu Island, Japan, overlapping the period of smoltification and seaward migration from August to March. Plasma T4 and cortisol were low in 0+ and 1+ year parr caught in August and September. In March, some yearling (1+ year) fish, which were judged as pre-smolts, and smolts appeared mainly in mid and lower reaches, while parr (0+ and 1+ year parr) continued to appear in the upper and mid reaches. In March, 1+ year pre-smolts and smolts showed high plasma T4 levels while the levels of 1+ year parr were low. During March 2008-2010, plasma T4 levels of 1+ year pre-smolts and smolts had high levels from early to mid-March, whereas plasma cortisol levels of 1+ year smolts were low in early March and increased towards mid-March. Based on these data, plasma cortisol increases probably occur following the increases of plasma T4 levels to lead the 1+ year O. masou to the completion of smoltification and initiation of seaward migration.

Seasonal changes in gene expression of corticoid receptors in anadromous and non-anadromous strains of rainbow trout Oncorhynchus mykiss.

To clarify the regulation of expression of corticoid receptor (CR) genes during period of parr-smolt transformation of salmonids, seasonal changes in mRNA levels of glucocorticoid receptor (GR)-1, GR-2 and mineralocorticoid receptor (MR) were examined in gill, leucocytes, spleen and brain of anadromous and non-anadromous forms of Oncorhynchus mykiss. Increases in gill Na(+) , K(+) ATPase activity, plasma thyroxine levels and hypo-osmoregulatory ability assessed by 24 h seawater challenge test represented characteristics of smoltification in anadromous O. mykiss from May to June, whereas there was no apparent increase in the values of non-anadromous O. mykiss. Plasma cortisol levels of anadromous O. mykiss were higher than levels of non-anadromous O. mykiss from April to June. In gill of non-anadromous O. mykiss, there were significant increases in mRNA levels of three types of CR in spring. Although there were significant seasonal variations of CR mRNA levels in gill of anadromous O. mykiss, they appear to be less clear than those variations in non-anadromous O. mykiss. In anadromous O. mykiss, significant elevations in mRNA levels of the three types of CR were observed especially in the spleen. In both preoptic area and basal hypothalamus of the brain, there were tendencies to increase in CR mRNA levels from spring to summer in both anadromous and non-anadromous O. mykiss. These results showed difference in regulation of CR gene expression between the two forms of O. mykiss for osmoregulatory, immune and central nervous systems.

Unexpected serum level of vancomycin after oral administration in a patient with severe colitis and renal insufficiency.

OBJECTIVE: To report a case in which the serum concentration of vancomycin (VCM) reached the supratherapeutic range following oral administration in a patient with severe pseudomembranous colitis and renal insufficiency. CASE SUMMARY: A 65-year-old, 70 kg weighing man with severe acute pancreatitis and acute renal failure was subjected to continuous hemodiafiltration (CHDF). CHDF could only be performed intermittently because of the unstable circulation dynamic of this patient. After admission, intravenous VCM therapy was initiated. Thereafter, oral VCM administration was begun (0.5 g every 6 h). Despite the discontinuation of intravenous VCM after the first 2 days of oral VCM, the serum VCM concentration increased gradually to 49.8 mg/l over a period of 2 weeks from the initiation of oral administration (34.4 mg/l). Based on pharmacokinetic analysis, the bioavailability of VCM was estimated to over 33%. Autopsy findings indicated broadly distributed necrosis on the lamina propria of the mucosa throughout all parts of the intestine below the duodenum. DISCUSSION: This case indicates necessity of the careful monitoring after oral high-dose VCM administration in a patient with a broadly distributed necrosis and renal insufficiency. CONCLUSIONS: TDM should be considered according to renal function, the severity of enteritis and the total dosage of oral VCM administration.

Paired inspiratory-expiratory thin-section CT findings in patients with small airway disease.

The objective of this study was to evaluate minimal small airway disease (SAD) as reflected on paired inspiratory-expiratory CT findings. Seventy-two subjects, 34 with SAD, 11 with normal lung function, and 27 with chronic obstructive pulmonary diseases (COPD), underwent thin-section CT during deep inspiration and expiration at upper, middle, and lower lung levels. Evaluation of CT measurement was performed between inspiratory and expiratory CT attenuation of lung parenchyma, in non-dependent and dependent lung at each of the three levels. Visual assessment of mosaic patterns and attenuation differences was also performed using the inspiratory and expiratory images. Patients with SAD were differentiated from those with COPD, by visual assessment and from the CT measurements. Visual assessment failed to differentiate between the SAD and normal groups. However, one measurement, an inspiratory-expiratory attenuation difference in the dependent lower lung, was different between SAD and normal group. Early small airway disease may be indicated by an inspiratory-expiratory attenuation difference in the dependent lower lung using the simple method of a paired inspiratory-expiratory CT.

Leptin-regulated endocannabinoids are involved in maintaining food intake.

Leptin is the primary signal through which the hypothalamus senses nutritional state and modulates food intake and energy balance. Leptin reduces food intake by upregulating anorexigenic (appetite-reducing) neuropeptides, such as alpha-melanocyte-stimulating hormone, and downregulating orexigenic (appetite-stimulating) factors, primarily neuropeptide Y. Genetic defects in anorexigenic signalling, such as mutations in the melanocortin-4 (ref. 5) or leptin receptors, cause obesity. However, alternative orexigenic pathways maintain food intake in mice deficient in neuropeptide Y. CB1 cannabinoid receptors and the endocannabinoids anandamide and 2-arachidonoyl glycerol are present in the hypothalamus, and marijuana and anandamide stimulate food intake. Here we show that following temporary food restriction, CB1 receptor knockout mice eat less than their wild-type littermates, and the CB1 antagonist SR141716A reduces food intake in wild-type but not knockout mice. Furthermore, defective leptin signalling is associated with elevated hypothalamic, but not cerebellar, levels of endocannabinoids in obese db/db and ob/ob mice and Zucker rats. Acute leptin treatment of normal rats and ob/ob mice reduces anandamide and 2-arachidonoyl glycerol in the hypothalamus. These findings indicate that endocannabinoids in the hypothalamus may tonically activate CB1 receptors to maintain food intake and form part of the neural circuitry regulated by leptin.

A metabolic defect promotes obesity in mice lacking melanocortin-4 receptors.

Melanocortin-4 receptor (Mc4r)-null mice exhibit late-onset obesity. To determine whether aberrant metabolism contributes to the obesity, food consumption by Mc4r-null mice was restricted to (pair-fed to) that consumed by wild-type (WT) mice. Pair-fed Mc4r-null females maintained body weights intermediate to that of WT and nonpair-fed Mc4r-null females, whereas pairfeeding normalized the body weights of Mc4r-null male mice. Fat pad and circulating leptin levels were elevated in both male and female pair-fed Mc4r-null mice compared with WT mice. Oxygen consumption of Mc4r-null mice with similar body weights as WT controls was reduced by 20%. Locomotor activity of young nonobese Mc4r-null males was significantly lower than that of WT males; however, locomotion of young nonobese females was normal. Core body temperature of Mc4r-null mice was normal, and they responded normally to cold exposure. Young nonobese Mc4r-null females were unable to induce uncoupling protein 1 (UCP1) in brown adipose tissue in response to peripheral leptin administration, whereas UCP1 mRNA was increased by 60% in the WT females. These results indicate that Mc4r deficiency enhances caloric efficiency, similar to that seen in the agouti obesity syndrome and in melanocortin-3 receptor-null mice.

A preliminary study of discrimination among the components of small pulmonary nodules by MR imaging: correlation between MR images and histologic appearance.

PURPOSE: To investigate whether magnetic resonance (MR) imaging depicts the internal characteristics of small pulmonary nodules. METHODS: We reviewed MR images of 39 surgically resected pulmonary nodules 3 cm or less and compared the components within the nodules. In 22 malignant nodules, eight histologic components were characterized by signal and enhancement patterns on MR images. RESULTS: MR images obtained from any single sequence discriminated all components in 26 (67%) nodules, whereas the combination of images from various sequences allowed discrimination in 35 (90%). Fourteen of 16 components of aggregated tumor cells showed marked early enhancement. Although fibrotic and necrotic components showed no or slight early enhancement, nine of 10 fibrotic components showed hypointensity and six of seven necrotic components showed hyperintensity on T2-weighted images. Component characterization in eight histologies by MR imaging was possible in 71-100%. CONCLUSION: Our study demonstrated that MR imaging offers the possibility of high tissue-contrast resolution in small pulmonary nodules.

Neurobiological responses to ethanol in mutant mice lacking neuropeptide Y or the Y5 receptor.

We have previously shown that voluntary ethanol consumption and resistance are inversely related to neuropeptide Y (NPY) levels in NPY-knockout (NPY -/-) and NPY-overexpressing mice. Here we report that NPY -/- mice on a mixed C57BL/6Jx129/SvEv background showed increased sensitivity to locomotor activation caused by intraperitoneal (ip) injection of 1.5 g/kg of ethanol, and were resistant to sedation caused by a 3.5-g/kg dose of ethanol. In contrast, NPY -/- mice on an inbred 129/SvEv background consumed the same amount of ethanol as wild-type (WT) controls at 3%, 6%, and 10% ethanol, but consumed significantly more of a 20% solution. They exhibited normal locomotor activation following a 1.5-g/kg injection of ethanol, and displayed normal sedation in response to 2.5 and 3.0 g/kg of ethanol, suggesting a genetic background effect. Y5 receptor knockout (Y5 -/-) mice on an inbred 129/SvEv background showed normal ethanol-induced locomotor activity and normal voluntary ethanol consumption, but displayed increased sleep time caused by 2.5 and 3.0 g/kg injection of ethanol. These data extend previous results by showing that NPY -/- mice of a mixed C57BL/6Jx129/SvEv background have increased sensitivity to the locomotor activation effect caused by a low dose of ethanol, and that expression of ethanol-related phenotypes are dependent on the genetic background of NPY -/- mice.

Does granulocyte colony-stimulating factor exacerbate radiation-induced acute lung injury in rats?

Radiation pneumonitis (RP) frequently occurs as a complication of thoracic irradiation. However, the mechanism of RP is not well known.. Activated neutrophils are a possible pathogenesis of RP. Neutrophil activation induced by granulocyte colony-stimulating factor (G-CSF) may exacerbate RP. We studied the effects of recombinant human G-CSF on acute lung injury induced by thoracic irradiation using rats. Animals were divided into three groups: sham irradiation with saline control, irradiation alone, and irradiation with G-CSF. Actual irradiation was given as a single fraction of 16 Gy delivered to the right hemithorax. G-CSF at a dose of 12 microg/body was administered subcutaneously once a day from 14 to 18 days after actual irradiation. Lung injury was evaluated 21 days after irradiation by bronchoalveolar lavage (BAL) fluid findings and the lung wet/dry weight (W/D) ratio. Neutrophil and lymphocyte counts in BAL fluid and the W/D ratio were significantly increased in the irradiation alone and the irradiation with G-CSF groups compared with those of the sham irradiation + saline control group. However, there was no significant difference observed between the irradiation alone and irradiation with G-CSF groups. In conclusion, this study suggests that postradiation administration of G-CSF does not exacerbate acute lung injury induced by thoracic irradiation in rats.

Effects of neuropeptide Y deficiency on hypothalamic agouti-related protein expression and responsiveness to melanocortin analogues.

Central administration of neuropeptide Y (NPY) potently induces feeding and its abundance in the hypothalamus increases when energy stores fall. Consequently, NPY is considered to be a physiological effector of feeding behavior. Surprisingly, NPY-deficient (NPY-/-) mice feed and grow normally with ad libitum access to food and manifest a normal hyperphagic response after fasting, suggesting that other feeding effectors may compensate for the lack of NPY. Agouti-related protein (AgRP), a melanocortin receptor antagonist, can also stimulate feeding behavior when administered centrally and is coexpressed in a majority of hypothalmamic NPY-ergic neurons, making AgRP a candidate compensatory factor. To test this possibility, we evaluated AgRP mRNA and protein expression, as well as responsiveness to centrally administered AgRP in NPY-/- mice. These studies demonstrate that hypothalamic AgRP mRNA and immunoreactivity are upregulated with fasting and that these increases are not affected by NPY deficiency. Interestingly, NPY-/- mice are hypersensitive to central administration of AgRP(83-132), yet exhibit a normal response to centrally administered MTII, a melanocortin receptor agonist. These data suggest that if AgRP compensates for the lack of NPY in NPY-/- mice, it is not at the level of AgRP synthesis and may instead involve alterations in the postsynaptic signaling efficacy of AgRP. Moreover, the effects of AgRP are not limited to its actions at the melanocortin-4 receptor (MC4R), because MC4R-deficient (MC4R-/-) mice manifest a significant response to centrally administered AgRP. These data imply that AgRP has additional targets in the hypothalamus.

[A case of fibrous histiocytoma of the appendix with twisted stalk].

A 74-year-old man consulted this hospital with the chief complaint of lower right abdominal pain on February 13, 1998. He was hospitalized, subjected to abdominalechography and CT, and diagnosed as having subileus caused by an intraperitoneal tumor. Surgery was performed on February 25, 1998. When the abdomen was incised, a chicken egg-sized tumor at the end of theappendix were found. In addition, the stalk of the appendix was twisted. Appendectomy was therefore performed. Upon histopathological examination, it was found that the submucosal tumor originated at the end of the appendix, and proliferation of spindle-shaped fibroblast-like cells and histocytic oval cells was observed in the tumor. Since various histiocyte markers were positive upon immunohistological examination, the tumor was considered to be of histiocytic origin. However, the tumordid not exhibit polymorphism, heteromorphism, or mitotic figures which would confirm a diagnosis of malignant fibrous histiocytoma. It was thus diagnosed as a fibrous histiocytic tumor on the borderline between malignant and benign. We report the present case because the occurrence of a primary fibrous histiocytoma in an appendix of which the stalk is twisted is very rare.

201Tl SPECT as an indicator for early prediction of therapeutic effects in patients with non-small cell lung cancer.

This study retrospectively investigated the good parameters on thallium-201 chloride (201Tl) SPECT for early assessment of the therapeutic effects in patients with non-small cell lung cancer. Based on tumor response as determined by chest CT scan about 9 weeks after the end of irradiation with adjuvant chemotherapy, the subjects were divided to the responder group (tumor regression > 50%, n = 13) and non-responder group (tumor regression < 50%, n = 13). 201Tl SPECT was performed before and at the halfway through the course of therapy (average tumor dose, 27.4 Gy +/- 4.5) in all the patients. SPECT was conducted twice 15 min (early scan) and 120 min (delayed scan) after intravenous injection of 148 MBq (4 mCi) of 201Tl. Tumor-to-contralateral normal lung tissue count ratios on both scans were calculated as early and delayed uptake ratios (EUR and DUR), and a retention index (RI) was also derived from these ratios. In the responder group, a significant decrease in DUR and RI halfway through the therapy was observed compared to pretreatment (2.6 +/- 0.6 vs. 3.5 +/- 1.0; p < 0.01, and -2.3% +/- 25.5 vs. 37.4% +/- 17.8; p < 0.001, respectively), even though EUR did not change significantly (N.S.). By contrast, in the non-responder group, there were no significant changes in any of these parameters (N.S.). When comparing DUR and RI for the two groups halfway through the therapy, DUR and RI were significantly lower in the responder group (both; p < 0.01), but no significant difference was noted in EUR (N.S.), and the percent reduction in tumor size did not correlate with the percent decrease in DUR or RI (N.S.). These results indicate that the extent of decrease in DUR and RI after therapy can be a useful parameter for early assessment of the therapeutic effects in patients with non-small cell lung cancer.

Radionuclide angiography and ventilation/perfusion studies in two patients with systemic arterial supply to the basal segment of the left lung.

The findings of radionuclide studies in two adult men with systemic arterial supply to the basal segment of the left lung without sequestration are reported. Radionuclide angiography with Tc-99m human serum albumin-diethylenetriamine showed that the lung was perfused by the systemic circulation rather than by the pulmonary artery. Ventilation and perfusion scans with Xe-133 and Tc-99m MAA showed a V/Q mismatch in this area, suggesting the presence of normal bronchial communication without a pulmonary arterial supply. These results also suggest the presence of a left-to-left shunt in the well-ventilated lung in this area. MRI and conventional angiography showed an aberrant artery arising from the descending thoracic aorta, supplying the basal segment of the left lung without a pulmonary artery. In both patients, left lower lobectomy showed normal alveobronchial structures without sequestration. Radionuclide angiography and ventilation/perfusion imaging appear to be reliable noninvasive methods for diagnosing this rare anomaly with a left-to-left shunt.

Thin-section oblique CT with 25 degrees cranially tilted images. Evaluation of pulmonary tumors adjacent to the interlobar fissures.

PURPOSE: Thin-section oblique CT with cranially tilted axial scans can provide better visualization of the interlobar fissures than thin-section CT with conventional axial scans. The purpose of this study was to evaluate the usefulness of oblique CT scans for pulmonary tumors adjacent to the interlobar fissures. MATERIAL AND METHODS: Cranially tilted and conventional axial images were obtained by thin-section CT in 10 patients with solitary pulmonary tumors adjacent to the interlobar fissures. Conventional CT with a 2-mm collimation and thin-section oblique CT with a 25 degrees cranial tilt were obtained. RESULTS: The images obtained by thin-section oblique scanning visualized the relationship between the pulmonary tumor and the interlobar fissures in all 10 patients, whereas in 6 patients the thin-section conventional images did not. The pulmonary tumors in these 6 patients included all 5 that were adjacent to the minor fissures. CONCLUSION: Thin-section oblique CT may be more useful than thin-section conventional CT in evaluating the relationship between pulmonary tumors and the minor fissures.

Superimposition of In-111 platelet SPECT and CT/MR imaging in intracardiac thrombus.

An initial attempt to superimpose in-111-labeled platelet SPECT over CT/MRI in two patients with intracardiac thrombus is presented. One patient was a 65-year-old woman with a history of mitral and tricuspid valve replacement. This patient had a large thrombus measuring 74 x 43 x 34 mm in the right atrium. Fusion imaging with CT showed increased in-111 activity on the surface of the thrombus, which was visualized as circular activity on a planar image. The other patient was a 72-year-old woman who had a thrombus measuring 17 x 14 x 12 mm at the cardiac apex. Planar imaging showed two discrete areas of abnormal in-111 activity. Superimposition of the SPECT image over MR revealed that one of these areas corresponded to the small thrombus, whereas the other related to a previous subendomyocardial biopsy. In both patients, the activity ratio of the abnormal in-111 accumulation versus the cardiac chamber on SPECT was greater than that on planar images. The correlation of in-111 platelet SPECT and CT/MRI was useful in accurately localizing the intracardiac thrombus.

High resolution CT findings in community-acquired pneumonia.

PURPOSE: Our goal was to clarify the high resolution CT (HRCT) findings of community-acquired pneumonia based on pathologic findings and to make a differential diagnosis between bacterial and atypical pneumonias. METHOD: This study evaluated 32 cases with community-acquired pneumonia, including 18 cases with bacterial pneumonia and 14 cases with atypical pneumonia [mycoplasma pneumonia (n = 12), chlamydia pneumonia (n = 1), and influenza viral pneumonia (n = 1)]. HRCT images in these cases were space consolidation, ground-glass attenuation, thickening of the bronchovascular bundle, and distribution of abnormal attenuation. RESULTS: Bacterial pneumonia frequently showed air space consolidation with segmental distribution (72.2%) that tended to locate at the middle and outer zones of the lung. Atypical pneumonia frequently showed centrilobular shadow (64.3%), acinar shadow (71.4%), air space consolidation and ground-glass attenuation with lobular distribution (57.1 and 85.7%, respectively), and tendency of the lesions to distribute at the inner layer of the lung in addition to the middle and outer layers (85.7%). CONCLUSION: Characteristic HRCT findings of both bacterial and atypical pneumonia were demonstrated. These HRCT features seemed to reflect pathologic findings and the manner of lesional progression. This information may support the appropriate antibiotic therapy in medical practice.