Roles of Gonadotropin Receptors in Sexual Development of Medaka.

The gonadotropins, follicle-stimulating hormone (FSH) and luteinizing hormone (LH), are secreted from the pituitary and bind to the FSH receptor (FSHR) and LH receptor (LHR) to regulate gonadal development in vertebrates. Previously, using fshr-knockout (KO) medaka (Oryzias latipes), we demonstrated that FSH regulates ovarian development by elevating estrogen levels. However, the lhr-KO phenotype in medaka is poorly characterized. Here, we generated lhr-KO medaka using the transcription activator-like effector nuclease (TALEN) technique. We analyzed its phenotype and that of fshr-KO, lhr;fshr double-heterozygotes (double-hetero), and double-KO fish. All genetically male medaka displayed normal testes and were fertile, whereas fshr-KO and double-KO genetically female fish displayed small ovaries containing many early pre-vitellogenic oocytes and were infertile. Although lhr-KO genetically female fish had normal ovaries with full-grown oocytes, ovulation did not occur. Levels of 17α,20ß-dihydroxy-4-pregnen-3-one, which is required for meiotic maturation of oocytes and sperm maturation in teleost fish, were significantly decreased in all KO female medaka ovaries except for double-heteros. Further, 17ß-estradiol levels in fshr-KO and double-KO ovaries were significantly lower than those in double-heteros. These findings indicate that LH is necessary for oocyte maturation and FSH is necessary for follicle development, but that neither are essential for spermatogenesis in medaka.

Expression patterns of sex differentiation-related genes during gonadal sex change in the protogynous wrasse, Halichoeres trimaculatus.

The three-spot wrasse, Halichoeres trimaculatus, can change sex from female to male (i.e. protogyny) due to sharp decrease in endogenous estrogen. During the sex change, ovarian tissue degenerates and testicular tissue arises newly. Finally, ovarian tissue disappears completely and replaces into mature testis. In order to predict the molecular mechanisms controlling the processes of sex change, we investigated the expression patterns of four genes (rspo1, figla, sox9b and amh), which have been thought to be associated with ovarian/testicular differentiation in vertebrates. Expression levels of rspo1 and figla, which play important roles for ovarian differentiation in vertebrates, were stable until the middle stage of the sex change, and subsequently down-regulated. Therefore, it was indicated that decrease in rspo1 and figla could result from ovarian degeneration. On the other hand, basis on the expression pattern, it was indicated that sox9b and amh, which are involved in testicular differentiation in vertebrates, were implicated in testicular formation and spermatogenesis during the sex change as well. The present results could be fundamental information for investigating the relationship between these factors and E2 depletion, which is crucial trigger for sex change.

Relationship between Vertebral Artery Hypoplasia and Posterior Circulation Ischemia.

PURPOSE: Vertebral artery hypoplasia (VAH) is a common congenital anatomical variation. In previous reports, it was unclear whether VAH was an independent risk factor for posterior circulation ischemia. The purpose of this study was to evaluate the impact of VAH on posterior circulation ischemia. METHODS: Subjects were patients with acute ischemic stroke who underwent brain magnetic resonance imaging (MRI) and carotid ultrasonography. Diagnostic criteria for VAH were as follows: (1) Vertebral artery (VA) diameter less than 2.5 mm; (2) VA diameter less than 3.0 mm and a difference in length equal to or greater than 1:1.7; (3) VA diameter less than 3.0 mm, peak systolic velocity less than 40 cm/second, and resistance index value greater than .75. The patients were categorized by the location of the ischemic stroke on MRI as follows: lesion in posterior circulation (P group), lesion in anterior circulation (A group), and multiple lesions in both the anterior and posterior circulations (AP group). RESULTS: We evaluated 129 consecutive patients. VAH was seen in 39, and VA occlusion was found in 15. The prevalence of VAH in the P group (44.4%) was significantly higher than that in the A + AP group (24.7%, P = .034). Multivariate regression analysis showed that large-artery atherosclerosis (odds ratio, 6.3; 95% confidence interval [CI], 1.3-30.1), posterior circulation ischemia (odds ratio, 12.0; 95% CI, 2.8-51.2), and VAH (odds ratio, 4.2; 95% CI, 1.2-15.0) were independent factors related to VA occlusion. CONCLUSION: VAH was an independent factor related to VA occlusion. Therefore, VAH likely plays a role in posterior circulation ischemia.

Early initiation of steroid pulse therapy for neuromyelitis optica in an emergency room setting.

Case: A 40-year-old man presented to the emergency room with visual impairment, dysesthesia of lower legs, and urinary retention. Two days before admission, he was consulted to the neurology department due to bilateral optic neuritis and scheduled the magnetic resonance imaging of spine. However, the urinary retention deteriorated acutely and he came to the emergency room. On arrival, the plain magnetic resonance image of his spine showed diffuse hyperintensity signals of the spinal cord in T2-weighted images. He was diagnosed with neuromyelitis optica and steroid pulse therapy was initiated. Outcome: We began treatment immediately in the emergency room, cooperating with the neurology team. After admission, plasmapheresis was added for his fluctuating symptoms. On hospital day 7, he was discharged without complication. Conclusion: It is important to understand the various clinical manifestations of neuromyelitis optica. In emergency settings, immediate steroid therapy is necessary for better outcomes.

[A Case of Tubercular Prostatic Abscess Following Intravesical Bacillus Calmette-Guerin Therapy].

We report a case of tubercular prostatic abscess. A 65-year-old man had undergone intravesical Bacillus Calmette-Guerin therapy for a non-muscle invasive bladder carcinoma. One year 8 months later, the prostate-specific antigen concentration in serum was elevated (18. 58 ng/ml). Results of magnetic resonance imaging (MRI) of the pelvis led us to suspect a prostatic abscess, and transurethral resection of the prostate for drainage was performed. A culture of fluid obtained from the latter procedure revealed a tubercular prostatic abscess. We administered the antituberculous agents, isoniazid (300 mg) and rifampicin(450 mg) daily, for 6 months. One year after surgery, the patient had no urinary symptoms or evidence of recurrence.

Sexual characteristics of high-temperature sterilized male Mozambique tilapia, Oreochromis mossambicus.

INTRODUCTION: In order to clarify the effect of extremely high temperature on gonads of fish, juveniles of the Mozambique tilapia, Oreochromis mossambicus, at three days after hatching (d.a.h.) were reared at a high temperature (37 ± 0.5 °C) for 50 days. The heat-treated fish were then cultivated at a normal water temperature for over six months. RESULTS: The testes of all individuals heat-treated for 50 days were sterile. Histological analysis revealed the complete absence of all stages of spermatogenic germ cells in the testes of the heat-treated males; however, structures within a layer of epithelial cells lining the efferent ducts were observed to actively secrete sperm fluid into the ducts, as in the mature testes of normal males. Clusters of cells immunopositive against P450scc and 3ß-hydroxysteroid dehydrogenase were observed in the sterilized testes. Leydig cells had developed smooth endoplasmic reticulum and several mitochondria with tubular cristae indicating active steroidogenesis. The sterilized males displayed male nuptial coloration, actively dug spawning nests, and mated with normal mature females. However, females mated with these males initially brooded their eggs normally but released them prematurely at 4-5 days. All the released eggs were unfertilized and dead. CONCLUSION: Heat-sterilized male tilapia matures endocrinologically but completely lacks spermatogenic germ cells.

[Radiation-induced lumbosacral plexopathy with severe burning pain after 17 years of radiation therapy for cervical cancer: a case report].

A 73-year-old woman was admitted with severe burning pain, hyperesthesia, and weakness in the right lower extremity. The patient had undergone radio- and chemotherapy after surgery for cervical cancer 17 years earlier. We diagnosed radiation-induced lumbosacral plexopathy because of conduction block in the deep peroneal nerve and myokymic discharge in the tibialis anterior muscle. Pelvic computed tomography and magnetic resonance imaging ruled out recurrent tumor and nerve-compressing lesions. Although radiation-induced lumbosacral plexopathy is usually characterized by lower motor neuron syndrome, we report a rare case presenting with severe pain and hyperesthesia.

Clinical Characteristics of Intracranial Reversed Vertebral Artery Flow Evaluated by Transcranial Color Flow Imaging.

BACKGROUND: Carotid duplex ultrasonography (CUS) has been used to identify reversed vertebral artery flow (RVAF) at the extracranial cervical artery in some patients with subclavian steal syndrome. However, the characteristics of intracranial RVAF as evaluated by transcranial color flow imaging (TC-CFI), which can examine intracranial hemodynamics in a real-time and noninvasive fashion, remain unclear. The goal of this study was to analyze the prevalence of intracranial RVAF and its associated clinical characteristics. METHODS: Subjects were consecutive patients who underwent TC-CFI and CUS. We evaluated blood flow in both intracranial vertebral arteries (VAs) from the suboccipital echo window using TC-CFI. RVAF was defined as a flow signal directed toward the probe. We calculated the prevalence of intracranial RVAF in our subjects. Then, we investigated vascular condition (ie, site of lesion, stenosis, occlusion, and dissection) using magnetic resonance angiography, computed tomography angiography , and CUS in patients with intracranial RVAF. RESULTS: Seven hundred twenty patients (508 men; median age, 73 years) were included in this study from September 2007 to March 2013. Intracranial RVAF was seen in 12 patients (1.7%; 11 men; median age, 61 years). Among the 12 patients with intracranial RVAF, 8 patients (67%) had ischemia of the vertebrobasilar territory with distal VA occlusion, according to CUS. Of those patients, 6 (75%) had dissection of the VA. CONCLUSIONS: TC-CFI detected intracranial RVAF in 1.7% of consecutive examinations in our facility. In vertebrobasilar territory stroke patients with intracranial RVAF, VA dissection may contribute to the development of stroke.

Living-donor kidney transplant from a type a donor to a type a subgroup recipient.

Type A subgroup is rare in Japan, and kidney transplant to a type A subgroup recipient is rare worldwide. A 65-year-old man presented for living-donor kidney transplant. Blood group testing showed that his wife (kidney donor) had blood group type A. The patient (recipient) had a type A subgroup because reverse blood grouping showed a weak reaction with A1 antigen. Further testing showed that the recipient had type A subgroup between Ax and Ael because adsorption elution experiments and flow cytometry showed a few A antigens that were not detected on forward grouping, and DNA analysis was not consistent with Ael. The patient was given a milder protocol for immunosuppressive preoperative therapy than typically used for ABO-incompatible kidney transplant; mycophenolate mofetil and prednisolone were started 3 weeks and cyclosporine 2 weeks before transplant, rituximab (100 mg) was given once, and double filtration plasmapheresis and plasma exchange were not used. Follow-up at 9 months after transplant showed stable clinical status and no allograft rejection. In summary, the present case showed that when type A subgroup recipient has low level of anti-A1 antibody and is receiving a kidney transplant from a blood type A donor, milder immunosuppressive preoperative therapy appears safe.

[Complete atrioventricular block due to cardiac metastasis from bladder cancer: case report].

A 72-year-old woman was diagnosed with bladder cancer (cT3bN0M0). After 2 cycles of GC (gemcitabine，cisplatin) neoadjuvant chemotherapy, the patient underwent a cystectomy and ileal conduit construction. Pathological findings showed urothelial carcinoma, high grade, G2＞G3, pT3a, INFß, ly0, v1. Six months after the operation, metastases to the liver, lung, left adrenal gland, rib, multiple lymph nodes, and peritoneum were revealed. Under palliative care, she suffered from palpitation and general fatigue. Electrocardiogram findings showed a complete atrioventricular block, while echocardiography and computed tomography revealed cardiac metastasis. We diagnosed her with complete atrioventricular block due to cardiac metastasis from bladder cancer. She died 7 days after onset of the complete atrioventricular block without use of a pacemaker.

[Posterior reversible encephalopathy syndrome (PRES) after kidney transplantation: a case report].

A 60-year-old woman with chronic renal failure due to a polycystic kidney underwent living kidney transplantation. Initial immunosuppressive therapy consisted of tacrolimus (TAC), mycophenolate mofetil (MMF), prednisolone, and basiliximab. Furthermore, rituximab was administered, and double filtration plasmapheresis and plasma exchange were utilized because of ABO-incompatible transplantation, while intravenous immune serum globulin (IVIG) was given because donor specific antibody was positive. Four days after the renal transplantation, the patient developed visual abnormalities, a headache, and paralysis. Then, he became unconscious. Magnetic resonance imaging of the brain demonstrated bilateral posterior vasogenic edema. Our diagnosis was posterior reversible encephalopathy syndrome due to TAC neurotoxicity. After converting TAC to reduced cyclosporine and everolimus, the symptoms rapidly disappeared.

[Small fiber neuropathy in a patient with complete Heerfordt syndrome manifesting as refractory facial pain].

We report a case of complete Heerfordt syndrome accompanied by the involvement of small fiber neuropathy (SFN) manifesting as refracory facial pain. A 30-year-old man presented with pyrexia, a 2-week history of facial burning pain, and difficulty of mastication. After admission to our hospital, neurological examinations showed bilateral facial pain, trigeminal motor palsy, left facial nerve palsy, bilateral sensory neural deafness, uveitis and swelling of the parotid gland. Other examinations revealed bilateral hilar lymphadenopathy, high serum titer of angiotensin coenzyme, and no response in a tuberculin-tested, non-caseating epithelioid granuloma from lip biopsy, leading to the diagnosis of complete Heerfordt syndrome. Mandibular skin biopsy with immunostaining for PGP 9.5 showed SFN. High-dose corticosteroids proved somewhat effective against SFN as facial pain, but reducing the corticosteroid dose proved difficult, as symptoms were refractory to other immunosuppressants and pain-control drugs such as anti-epileptics and anti-depressants. The patient died of acute pancreatitis 3 years after disease onset. Autopsy showed no granuloma in hilar lymph node, trigeminal nerve, cranial base, nerve root, and muscle. SFN in this case probably represent a cause of refractory facial pain.

[Sertoli cell tumor of the testis : a case report and questionnaire survey on the reported cases in Japan].

We report a case of Sertoli cell tumor of the testis. A 33-year-old man visited our hospital with the complaints of macroscopic hematuria and fever. The left testis was swollen on palpation. Serum levels of human chorionic gonadotropin-ß and lactate dehydrogenase were not elevated, while α fetoprotein was slightly over the normal range. Ultrasonography showed a hypoechoic lesion in the left testis. There was no evidence of retroperitoneal lymph node enlargement or distant metastasis on computed tomography. A left orchietectomy was performed under the diagnosis of left testicular tumor. The tumor, measuring 20 mm in size was histologically diagnosed as benign Sertoli cell tumor. No adjuvant therapy was performed. Neither recurrence nor evidence of metastasis has been detected for 6 months postoperatively.

Loss of follicle-stimulating hormone receptor function causes masculinization and suppression of ovarian development in genetically female medaka.

FSH, a glycoprotein hormone, is circulated from the pituitary and functions by binding to a specific FSH receptor (FSHR). FSHR is a G protein-coupled, seven-transmembrane receptor linked to the adenylyl cyclase or other pathways and is expressed in gonadal somatic cells. In some nonmammalian species, fshr expression is much higher in the ovary than in the testis during gonadal sex differentiation, suggesting that FSHR is involved in ovarian development in nonmammalian vertebrates. However, little is known of FSHR knockout phenotypes in these species. Here we screened for fshr mutations by a medaka (Oryzias latipes) target-induced local lesion in the genomes and identified one nonsense mutation located in the BXXBB motif, which is involved in G protein activation. Next, we used an in vitro reporter gene assay to demonstrate that this mutation prevents FSHR function. We then analyzed the phenotypes of fshr mutant medaka. The fshr mutant male medaka displayed normal testes and were fertile, whereas the mutant female fish displayed small ovaries and were infertile because vitellogenesis was inhibited. The mutant females also have suppressed expression of ovary-type aromatase (cyp19a1a), a steroidogenic enzyme responsible for the conversion of androgens to estrogens, resulting in decreased 17ß-estradiol levels. Moreover, loss of FSHR function caused female-to-male sex reversal in some cases. In addition, the transgenic overexpression of fshr in fshr mutants rescued FSHR function. These findings strongly suggest that in the medaka, FSH regulates the ovarian development and the maintenance mainly by the elevation of estrogen levels. We present the first FSHR knockout phenotype in a nonmammalian species.

[A case of urachal carcinoma with multiple lung metastases treated by TS-1/CDDP chemotherapy].

A 67-year-old woman presented with macroscopic hematuria and lower abdominal pain. Cystoscopy revealed a broad-stalk non-papillary tumor at the bladder dome. Computed tomography (CT) showed a tumor extending from the umbilicus to the bladder dome, together with multiple lung metastases. Serum carcinoembryonic antigen and cancer antigen (CA19-9) levels were elevated at 7.0 ng/ml and 180 U/ml, respectively. Transurethral resection of the tumor was performed and histopathology revealed adenocarcinoma. Therefore, the tumor was diagnosed as a stage IVB (Sheldon's category) urachal carcinoma. En bloc segmental resection of the urachal carcinoma with the bladder dome was performed, followed by chemotherapy with tegafur, gimestat, and otastat potassium (TS-1) and cisplatin. The disease remained stable for 8 months. However, a follow up CT scan after 11 chemotherapy cycles showed progression of the lung metastases. In spite of the change to a second-line gemcitabine and cisplatin chemotherapy regimen, the disease continued to progress after 4 cycles.

Characterization of gonadal soma-derived factor expression during sex change in the protogynous wrasse, Halichoeres trimaculatus.

BACKGROUND: Sex change in fishes provides a good experimental model for understanding the mechanisms and plasticity of sex determination and differentiation. The three-spot wrasse, Halichoeres trimaculatus is a protogynous hermaphrodite. During sex change from female to male, the ovary is replaced by the testis through the degeneration of oocytes and subsequent spermatogenesis. In the present study, we cloned a cDNA-encoding gonadal soma-derived factor (GSDF) from protogynous wrasse and examined its expression pattern in the sexually mature gonads and the sex-changing gonad induced experimentally by aromatase inhibition. RESULTS: Expression of gsdf was predominantly observed in the testis, and it was mainly localized to the supporting cells surrounding the spermatogonia. In the ovary, only slight expression of gsdf was observed in morphologically undifferentiated supporting cells in contact with oogonia. During sex change, strong expression of gsdf appeared first in the supporting cells surrounding the gonial germ cells before the onset of spermatogenesis. Thereafter, the expression of gsdf continually increased in the supporting cells surrounding the proliferating spermatogonia throughout the sex change. CONCLUSIONS: These results suggest that gsdf is involved in the proliferation of spermatogonia and subsequent spermatogenesis in both the testis and the gonad in the early stages of sex change.

[Dopamine-secreting pheochromocytoma with neurofibromatosis type 1 : a case report].

Pheochromocytoma occurs in 0.1-5.7% of patients with neurofibromatosis type 1 (NF1), while dopamine-secreting pheochromocytoma is rare. We report here a rare case of dopamine-secreting pheochromocytoma in a patient with NF1. A 46-year-old woman with NF1 was referred to our hospital with epigastralgia. The patient had no history of hypertension. Abdominal sonography incidentally revealed a left adrenal tumor, while abdominal computed tomography and magnetic resonance imaging findings showed a left adrenal tumor, sized 63×58 mm. Laboratory evaluations revealed exclusively elevated urine dopamine levels in addition to elevated serum adrenaline and noradrenaline levels. Laparoscopic left adrenalectomy was performed and the dopamine levels and other cathecolamine levels returned to normal postoperatively.

Immunohistochemical features of BK virus nephropathy in renal transplant recipients.

BK virus nephropathy (BKVN) is one of the factors that reduces renal graft function after transplantation. However, BKVN and rejection present similar pathological findings, as both are accompanied by cellular infiltration to the interstitium and tubulitis, thus they are difficult to distinguish for diagnosis and medical treatment. In the present study, we examined immunohistochemical pathological features of BKVN in four cases treated in our hospital from 2007 to 2010. Common immunohistological finding is that tubulitis in these cases was primarily EMA and 34ßE12-positive and existed predominantly from the collecting duct to the distal convoluted tubule. The majority of infected cells existed in EMA and 34ßE12-positive tubules, which were also located mainly from the collecting duct to the distal tubule. In addition, a large number of SV40-positive infected cells were similarly seen. Dylon staining clearly revealed eosinophils. We concluded that the main pathological features of BKVN are the presence of tubulitis and infected cells predominantly from the collecting duct to distal tubule and the appearance of eosinophils.

[A case of malignant peritoneal mesothelioma presenting with bilateral swelling of spermatic cord].

A 67-year-old man had pain and swelling in the bilateral inguinal region. His past medical history included non-alcoholic steatohepatitis and liver cirrhosis. A clinical examination revealed a solid mass that was palpable along with the bilateral spermatic cord from the external inguinal ring to the root of the scrotum. Other than a hydrocele in the right testis, the epididymis and testes were intact. Abdominal computed tomography showed ascites and a solid tumor of the bilateral spermatic cord. Magnetic resonance imaging findings did not suggest malignancy, while antibiotics showed no effects. The patient wanted relief from the inguinal pain and a bilateral high orchiectomy was performed, during which time the spermatic cord was found firmly adhered to the surrounding tissue, and could not be completely resected. A histopathological examination showed epithelial mesothelioma. For additional examination of the ascites, the patient underwent paracentesis, which revealed an extremely high level of hyaluronic acid. Our working diagnosis was peritoneal malignant mesothelioma that had infiltrated the bilateral spermatic cord. We began systemic chemotherapy treatment with pemetrexed and cisplatin, but, the patient died 3 months after the operation.