Increasing C-reactive protein levels in a patient with glioblastoma with lymph node metastasis: a case report.

BACKGROUND: Glioblastoma usually recurs locally and extracranial metastases are rare. Most patients with extracranial metastases experience recurrence of the primary intracranial tumor. Lymph node metastases are often detected based on lymphadenopathy or symptoms caused by other metastatic sites. CASE PRESENTATION: Herein, we report a case of glioblastoma with lymph node metastasis in which the patient was asymptomatic but exhibited gradually increasing C-reactive protein levels prior to becoming febrile 9 months after the initial C-reactive protein increase. Diagnosis of lymph node metastasis that was delayed because the patient had a fever of unknown origin, no signs of infection, and the primary intracranial tumor did not recur. Chest computed tomography indicated supraclavicular, mediastinal, and hilar lymphadenopathy, and biopsy identified lymph node metastasis of glioblastoma. This is the fifth reported case of lymph node metastasis without intracranial recurrence. CONCLUSIONS: C-reactive protein levels may be a diagnostic marker for lymph node metastasis in patients with glioblastoma. Further evaluation is needed to elucidate the role of CRP in glioblastoma with lymph node metastasis.

Evaluating the usefulness of Ninjin'yoeito Kampo medicine in combination with rehabilitation therapy in patients with frailty complicated by intractable dizziness.

Patients with chronic intractable dizziness (henceforth referred to as "intractable dizziness") have a high risk of developing frailty complications. This warrants investigation of a combined treatment for intractable dizziness and frailty. Ninjin'yoeito (NYT), a traditional Japanese medicine (Kampo medicine), is reportedly effective in treating frailty and sarcopenia. Herein, we report on the results of a retrospective study that involved the combined application of NYT and dizziness rehabilitation therapy (henceforth referred to as "dizziness rehabilitation"). Of the 31 patients with intractable dizziness, 14 developed frailty, indicating a complication rate of 45.2%. This in turn was approximately 4 times higher than the previously reported rates. Eleven patients became non-frail after 6 months of the combined treatment, and their improvement rate was 78.6%. The aforementioned combination therapy not only improved dizziness but also improved frailty. Following 6 months of combined treatment, patients in the frailty group exhibited improvement in the Dizziness Handicap Inventory score, frailty symptoms, Kihon checklist score, and visual analog scale score (fatigue), and approached the pre-treatment values of those in the non-frailty group. Together, our results highlight the need to combine the treatment for intractable dizziness and frailty.

A novel germline BMPR1A variant (c.72_73delGA) in a Japanese family with hereditary mixed polyposis syndrome.

Hereditary mixed polyposis syndrome (HMPS) is a rare autosomal dominant disorder characterized by a mixture of typical and/or atypical juvenile polyps, adenomas and hyperplastic polyps, resulting in an increased risk of colorectal cancer. In HMPS, four different germline BMPR1A variants from five unrelated families have been reported. This study is the first to report HMPS within a Japanese family. The proband underwent repeated colonoscopic polypectomies over a 5-year period, since the age of 67. Histological examination of these resected polyps revealed adenomas, juvenile-like polyps and hyperplastic changes. Genetic testing was conducted to identify the causative genes for hereditary gastrointestinal cancer syndromes, including BMPR1A. We detected a germline variant, c.72_73delGA, in BMPR1A. The proband's elder brother, younger sister and nephew have also undergone repeated colonoscopic polypectomies at other clinics. His sister and nephew underwent genetic testing, and the same BMPR1A variant was identified.

[Treatment of Mandibular Fracture-Associated Infectious Pseudarthrosis Accompanied by Osteomyelitis in a Peritoneal Dialysis Patient].

Peritoneal dialysis can be performed at home, and the transfer of solutes in the blood and other body fluids is slow compared to hemodialysis, reducing the load on the circulatory organs and lessening the frequency of hospital visits. We encountered a male patient in his 70s on peritoneal dialysis for end-stage renal failure who developed obsolete mandibular fracture-associated pseudarthrosis accompanied by osteomyelitis, which was treated with noninvasive reduction and fixation using circumferential wiring after the resolution of inflammation. The inflammation was resolved by an intravenous drip infusion of ampicillin and lavage of the local region through the fistulated region during hospitalization, and sequestrum was removed under local anesthesia. After the disappearance of drainage from the fistula, the mandibular fracture was fixed with circumferential wiring (noninvasive reduction and fixation) using a mandibular resin base (occlusion is possible). For noninvasive reduction and fixation of a midline fracture, a 6-week fixation period is usually necessary after surgery, but in this case it was fixed for 3 months after surgery because of the presence of infection and bone defect. In jaw bone infection in patients on long-term dialysis, high sensitivity to infection and incomplete cure occur due to a decline in cell-mediated immunity, renal osteodystrophy (ROD), and chronic kidney disease (CKD)-mineral and bone disorder. In the present patient, infection complicated the odontogenic source of infection and fracture, which may have protracted the condition. When jaw bone infection is noted in a patient on long-term dialysis, it is important to closely cooperate with the dialysis physician and select the administration method and dose corresponding to the route of administration and metabolism of antimicrobial agents in order to minimize the influence on the renal function. For the local region, infection control by oral hygiene management and cleaning is important, targeting treatment and management while avoiding the use of any antimicrobial agent.

Clinical and Radiological Discrimination of Solitary Pulmonary Lesions in Colorectal Cancer Patients.

OBJECTIVES: The lung is one of the most common organs of metastasis from colorectal cancer (CRC), and we have encountered lung cancer patients with a history of CRC. There have been few studies regarding methods used to discriminate between primary lung cancer (PLC) and pulmonary metastasis from CRC (PM-CRC) based only on preoperative findings. We retrospectively investigated predictive factors discriminating between these lesions in patients with a history of CRC. METHODS: Between 2006 and 2015, 117 patients with a history of CRC (44 patients with 47 PLC and 73 patients with 102 PM-CRC) underwent subsequent or concurrent resection of pulmonary lesions. We compared the clinical and radiological characteristics of 100 patients with solitary lesions (43 PLC and 57 PM-CRC). Using univariate and multivariate analyses, we examined predictive factors for discrimination of these two lesions. RESULTS: All tumors with findings of ground-glass opacity (GGO) were PLC (n = 19). In a multivariate analysis of 81 radiologically solid tumors, two factors were found to be significant independent predictors of PLC: a history of stage I CRC and presence of pleural indentation. All tumors in 26 patients with either GGO or both a stage I CRC history and pleural indentation were PLC, while most tumors in patients without all three factors were PM-CRC (43/44; 97.7%). CONCLUSIONS: The presence or absence of GGO, pathological CRC stage, and pleural indentation could be useful factors to distinguish between PLC and PM-CRC.

Prognostic impact of stathmin 1 expression in patients with lung adenocarcinoma.

OBJECTIVE: Stathmin 1 is a major cytosolic phosphoprotein that regulates microtubule dynamics and is associated with malignant phenotypes in various cancers, including non-small cell lung cancer. We aimed to determine differences in overall survival and disease-free proportion in patients with lung adenocarcinoma stratified by stathmin 1 tumor expression. METHODS: With the use of immunohistochemistry, stathmin 1 expression was determined in resection specimens from 303 patients with adenocarcinoma. Associations between stathmin 1 protein expression and overall and disease-free proportion were assessed (Kaplan-Meier survival curves compared with log-rank statistics). Cox proportional hazards regression determined the hazard for death stratified by stathmin 1, adjusting for clinicopathologic characteristics. RESULTS: During follow-up, 74 (24.4%) recurrences and 73 (24.1%) all-cause deaths were recorded. Expressed in 53.8% of adenocarcinoma cases, overall survival and disease-free proportion were significantly worse in stathmin 1-positive patients (log-rank P < .001 and P < .001, respectively). When adjusted for clinical and pathologic factors, stathmin 1 expression was an independent prognostic variable for both overall survival (hazard ratio, 2.21; 95% confidence interval, 1.28-3.80) and disease-free proportion (hazard ratio, 2.02; 95% confidence interval, 1.13-3.63) and for disease-free proportion even in the subset of patients with stage I (hazard ratio, 2.79; 95% confidence interval, 1.07-7.27). There was no significant difference between the stathmin 1-positive patients with stage IA and patients with stage IB in overall survival (P = .975) and disease-free proportion (P = .490), respectively. CONCLUSIONS: Stathmin 1 expression was an independent prognostic factor for adenocarcinoma, even when restricted to patients with early-stage cancer.

The influence of headaches in patients with chronic dizziness.

CONCLUSION: The frequency of headaches in patients complaining of chronic dizziness is closely related to the severity of the dizziness impairments and mood states, such as anxiety. It is, therefore, important to treat co-morbid headache in patients with chronic dizziness. The severity of the dizziness impairments and other mood states, including anxiety, did not differ between patients with migraine or non-migraine headaches. OBJECTIVES: Patients with chronic dizziness often complain of headaches or general fatigue. This study investigated the influence of the frequency of headaches on dizziness impairments, anxiety, quality-of-life, and other mood states in patients with chronic dizziness. METHOD: The subjects consisted of 100 consecutive patients with intractable dizziness. Several types of questionnaires were used in the investigations. RESULTS: Of the 85 patients, 51 had either type of headache (tension headache, 38; migraine, 13). The total score on the Dizziness Handicap Inventory correlated linearly with general fatigue (R = 0.39, p < 0.001) and headache (R = 0.25, p < 0.05). The patients with any type of headache had a significantly more positive family history of headache (p < 0.05).

Superficial siderosis of the central nervous system caused by hemorrhagic intraventricular craniopharyngioma: case report and literature review.

Superficial siderosis is a rare condition caused by hemosiderin deposits in the central nervous system (CNS) due to prolonged or recurrent low-grade bleeding into the cerebrospinal fluid (CSF). CNS tumor could be one of the sources of bleeding, both pre- and postoperatively. We report an extremely rare case of superficial siderosis associated with purely third ventricle craniopharyngioma, and review previously reported cases of superficial siderosis associated with CNS tumor. A 69-year-old man presented with headache, unsteady gait, blurred vision, and progressive hearing loss. Brain magnetic resonance (MR) imaging with gadolinium revealed a well enhanced, intraventricular mass in the anterior part of the third ventricle. T2*-weighted gradient echo (GE) MR imaging revealed a hypointense rim around the brain particularly marked within the depth of the sulci. Superficial siderosis was diagnosed based on these findings. The tumor was diffusely hypointense on T2*-weighted GE imaging, indicating intratumoral hemorrhage. The lateral ventricles were dilated, suggesting hydrocephalus. [(18)F]fluorodeoxyglucose positron emission tomography revealed increased uptake in the tumor. The whole brain surface appeared dark ocher at surgery. Histological examination showed the hemorrhagic tumor was papillary craniopharyngioma. His hearing loss progressed after removal of the tumor. T2*-weighted GE MR imaging demonstrated not only superficial siderosis but also diffuse intratumoral hemorrhage in the tumor. Superficial siderosis and its related symptoms, including hearing loss, should be considered in patients with hemorrhagic tumor related to the CSF space. Purely third ventricle craniopharyngioma rarely has hemorrhagic character, which could cause superficial siderosis and progressive hearing loss.

[Application of vestibular rehabilitation with an introduction session in patients with chronic dizziness].

Pharmacological and non-pharmacological approaches are the treatment options for dizzy patients. Vestibular exercises are a potential treatment option for intractable dizzy patients who do not respond to conventional drug therapy. The retention rate of exercises is quite important for a successful outcome. We organized vestibular exercise courses to improve the retention rate in the outpatient groups; these courses comprised introduction sessions with a clinical psychologist and rehabilitation sessions with a clinical technologist. It is unclear whether the effects of vestibular rehabilitation are based on the improvement of the psychological parameters of vestibular function. Therefore, we evaluated the functional mechanism of vestibular rehabilitation by using questionnaires and balance function tests. Our study comprised 16 patients with chronic dizziness. The patients performing the self-administered home-based vestibular exercise courses were supervised in small groups. The patients were taught that the exercises were to be performed 4 times a day at their respective homes. The symptoms of dizziness were evaluated using the Japanese version of the dizziness handicap inventory (DHI). Anxiety and depression levels were assessed using a set of psychological questionnaires. The static and dynamic balance function was assessed using static posturography and foam posturography and by measuring the time required for performing a certain series of eye-head movement protocols at the initial visit, before rehabilitation, and 2 and 3 months after rehabilitation. Of 16 patients, 15 could successfully complete the study (93.8%). The DHI score significantly improved 1 month after the rehabilitation, whereas anxiety and depression levels did not improve. The results of static and foam posturography as well as the time required for the eye-head movements also significantly improved. The improvement in the DHI scores was not associated with psychological changes, but with the improvement in the static and dynamic balance function.

Characteristic electroencephalographic findings by photic driving in patients with migraine-associated vertigo.

CONCLUSIONS: Patients with migraine-associated vertigo (MAV) may have a higher incidence of photic-driven electroencephalography (EEG) response. The occurrence of photic-driven responses for stimulation at frequencies of 10, 12, and 15 Hz can be considered a positive indicator for MAV. Although photic driving is not specific to migraine, patients with MAV have a higher incidence of photic driving. The distinction between Ménière's disease and MAV by means of EEG would be another interesting topic of research. OBJECTIVE: The objective of this study was to distinguish between patients with MAV and patients with other vestibulopathies (VPs) using EEG. METHODS: EEG with intermittent photic stimulation (PS) at frequencies between 3 and 24 Hz was recorded to quantify photic driving in patients with MAV (n = 21) and VPs (n = 15). The presence or absence of photic driving was determined; a score of 1 was counted for response to a particular frequency. RESULTS: Total scores were calculated for each patient for statistical comparison. There was a significant difference in the average total score between MAV and VP patients (p < 0.05), and photic-driven responses were observed for 10, 12, and 15 Hz stimulation.

Multiple papillary fibroelastomas of the aortic valve detected by real time three-dimensional transesophageal echocardiographic images.

Papillary fibroelastoma (PFE) is a well-known primary cardiac tumor, but multiple PFEs are rare. We report an interesting case with multiple PFEs that were clearly demonstrated and evaluated with real time three-dimensional (RT3D) transesophageal echocardiography (TEE). A 77-year-old woman was referred to our institution with a diagnosis of osteoarthritis of the hip. Transthoracic echocardiography showed an abnormal structure on the aortic valve. Although two-dimensional TEE revealed typical characteristics of multiple PFE, RT3D TEE clearly demonstrated their number and location on the right and non-coronary cusp of the aortic valve. These results were subsequently confirmed by surgery and pathological findings. RT3D TEE is an exceptionally useful tool for pre-surgical evaluation of PFE. .

Frequent IDH1/2 mutations in intracranial chondrosarcoma: a possible diagnostic clue for its differentiation from chordoma.

Mutations in the genes encoding isocitrate dehydrogenase (IDH) 1/2 have been detected in a significant proportion of diffuse gliomas and in a small fraction of acute myeloid leukemia (AML) cases. Recently, in an examination of various types of mesenchymal tumor, IDH1/2 mutations were only found in cartilaginous tumors including central conventional and periosteal enchondromas/chondrosarcomas. The frequency of IDH1/2 mutations was 56%, and the IDH1 R132C mutation, which is not common in diffuse gliomas or AML, accounted for 40% of these mutations. In this study, we investigated the IDH1/2 mutation status of intracranial chondrosarcomas and chordomas, which are morphologically similar and affect similar regions of the cranial cavity. Of the 13 chondrosarcomas analyzed, six (46.1%) displayed IDH1/2 mutations (the predominant type was IDH1 R132C). Also, an IDH2 mutation (R172S) was observed in one case. Conversely, none of the ten chordomas analyzed displayed any IDH1 or IDH2 mutations. Our data suggest that the IDH1/2 mutation status could be valuable for distinguishing intracranial chondrosarcomas from chordomas.

An immunohistochemical finding in glioneuronal lesions associated with epilepsy: the appearance of nestin-positive, CD34-positive and tau-accumulating cells.

Several kinds of unusual cells have been pathologically identified in epileptic patients. CD34-positive, nestin-positive and tau-positive cells are some of them. However, no reports have investigated the significance of these cells. We examined 14 cases of seizure-associated glioneuronal lesions to investigate the incidences and distributions of these cells and the association between their incidence and clinical parameters. CD34-positive and nestin-positive cells were seen in 43% and 50% of cases, respectively. In the regions with structural anomalies, there were increased numbers of CD34-positive cells and nestin-positive cells, but they were identified as different cells. Both examinations showed many abnormal processes in oligodendroglial-like cells with round nuclei. In contrast, few reactive astrocytes that demonstrated immunoreactivity for glial fibrillary acidic protein were found in this area. Tau accumulation was present in 37% of cases. There was no correspondence with the regions showing increasing numbers of nestin or CD34-positive cells. There were no significant associations between epileptic clinical parameters and the incidences of the abovementioned immunopositive cells. CD34-positive cells and nestin-positive cells are found as frequently as balloon cells and are associated with abnormal reconstitution of the cortex. These findings support the assertion that increases in the numbers of these cells might contribute to promoting epilepsy. In addition, these immunopositive cells are valuable findings for the pathological identification of epileptogenic lesions.

[Somatic symptoms in those hospitalized for dizziness or vertigo].

Anxiety and depression greatly affect the prognosis of and burden on subjects seen for dizziness or vertigo, who usually report multiple somatic symptoms. We studied the prevalence of these symptoms in 145 subjects hospitalized for dizziness or vertigo and taking part in 4-day group vestibular rehabilitation. Questionnaires given to determine the prevalence of somatic symptoms assessed headache, insomnia, diarrhea, constipation, stomachache, chest pain, palpitations, dyspnea, general fatigue, and stress. Quantitation used aerical rating scale (NRS). Anxiety and depression were assessed using the hospital anxiety and depression scale (HADS). Disability due to dizziness was assessed using the dizziness handicap inventory (DHI). We conducted correlational analysis between dizziness and somatic symptoms. The top four average NRS scores for somatic symptoms were dizziness at 3.5 +/- 2.8, general fatigue at 2.8 +/- 2.6, insomnia at 2.4 +/- 2.6, and headache at 1.8 +/- 2.3. These symptoms resembled those reported for subjects with anxiety and depression. The correlation between headache and dizziness NRS scores was R = 0.48 (P < 0.0001). The total HADS score was 13.9 +/- 8.1 points (anxiety 7.2 +/- 4.3, depression 6.7 +/- 4.3). The average DHI score was 36.3 +/- 24.1 points. These results indicate that those with dizziness reported several somatic symptoms related to anxiety and depression attributable to dizziness. This underscores the need to treat these somatic symptoms when treating subjects seen chiefly dizziness or vertigo.

[Traumatic internal carotid artery dissection due to compression by a helmet strap].

It is well known that wearing a helmet can reduce the risk of head injury in a traffic accident. We report a case of traumatic cervical internal carotid artery dissection due to compression by the strap of a helmet after a motorcycle accident. A 21 year-old man fell off his motorcycle and his head was struck at the right parietal region. His helmet prevented head injury, but the helmet strap which was fixed around his neck compressed his cervical internal carotid artery. He lost consciousness and developed left hemiparesis two hours after being admitted to an emergency department. Cerebral angiography revealed dissection of he right cervical internal carotid artery. This lesion was treated successfully by stent placement two months after the accident. The cause of carotid dissection was thought to be compression of his neck by the helmet strap. If the strap of a helmet is fixed around the neck, it can cause carotid artery injury during an accident, so it can be concluded that the strap of a helmet should be fixed firmly at the chin.