Mitochondrial encephalopathy, lactic acidosis, and stroke-like episodes diagnosed after metformin-triggered stroke-like episodes.

A 40-year-old man with sensorineural hearing loss and diabetes mellitus was hospitalized with acute-onset impaired consciousness and clumsiness in his left hand. He had been taking metformin for 4 months. A neurological examination revealed confusion and weakness in the left upper limb. Increased lactate levels were detected in the serum and cerebrospinal fluid. Magnetic resonance imaging revealed lesions in the right parietal and bilateral temporal lobes with a lactate peak in magnetic resonance spectroscopy. Finally, we made a genetic diagnosis of mitochondrial encephalopathy, lactic acidosis, and stroke-like episodes based on the detection of m.3243A>G. It is well-known that metformin should not be administered in patients with mitochondrial encephalopathy, lactic acidosis, and stroke-like episodes because metformin inhibits mitochondrial function and triggers stroke-like episodes. However, our patient was diagnosed with mitochondrial encephalopathy, lactic acidosis, and stroke-like episodes after metformin administration. Thus, we encourage physicians to exercise caution in the prescription of metformin in patients with short stature, sensorineural hearing loss, or young-onset diabetes mellitus because these patients may have undiagnosed mitochondrial encephalopathy, lactic acidosis, and stroke-like episodes.

Renal Leukemic Infiltration Overlapping Acute Focal Bacterial Nephritis during Myelodysplastic Syndrome: An Autopsy Case Report.

Renal leukemic infiltration is uncommon in myeloid neoplasms, including myelodysplastic syndromes (MDS). A 76-year-old male patient was admitted to our hospital with complaints of fever and dyspnea. He was diagnosed with MDS with multilineage dysplasia and acute focal bacterial nephritis (AFBN) based on clinical, laboratory, and radiological investigations. Antibiotic treatment temporarily improved his condition, but the radiological image of AFBN remained. His condition gradually deteriorated into multiple organ failure, and he unfortunately died on the 31st day of hospitalization. Autopsy findings revealed significantly increased p53-positive blasts in the bone marrow and renal parenchyma overlapping AFBN, suggesting leukemic transformation and renal infiltration. This case emphasizes the need to review the diagnosis when antibiotic treatment is ineffective in MDS patients with AFBN.

Suicide by plastic bag suffocation combined with the mixture of citric acid and baking soda in an adolescent.

We describe a case of suicidal asphyxiation using a plastic bag combined with carbon dioxide (CO2) gas. A 20-year-old male, whose head was covered with a plastic bag, was found dead in his room. In the plastic bag, there were two glass-made cups containing liquid-like substance. Through crime scene investigation by police staffs, a bottle of citric acid and a box of baking soda were also discovered in his room. The forensic autopsy revealed that there were neither lesions nor injuries in all of the organs. Moreover, any drugs and poisons could not be detected in blood samples. Based on autopsy findings and crime scene investigation, the cause of death was diagnosed as acute asphyxia due to CO2 intoxication by the mixture of citric acid with baking soda in the plastic bag. To the best of our knowledge, there are no medical literatures describing plastic bag suffocation combined with CO2 gas generated from citric acid and baking soda, which has been widely distributed as suicidal means through websites. This case report promotes forensic pathologists and medical coroners to emphasize that the Internet has a crucial role on a source of suicidal information or a promoter of suicide all over the world.

Three-year follow-up of rheumatoid meningitis with matrix metalloprotease-9 levels in the serum and cerebrospinal fluid as indicators of disease activity: A case report.

Rheumatoid meningitis (RM) is an extra-articular complication of rheumatoid arthritis (RA). Although reports of RM sine arthritis exist, most patients with this presentation were diagnosed with RA within one year of RM onset. There are no established biomarkers reflecting the disease activity of RM. This case report highlights the elevation of matrix metalloprotease (MMP)-9 levels during the acute phase of RM and decline during remission. Additionally, this is the first case report of RA diagnosed three years after the onset of RM. It is important to further validate the utility of MMP-9 and conduct long-term follow-up of RM sine arthritis.

Prevalence, Impact, and Screening Methods of Sarcopenia in Japanese Patients With Parkinson's Disease: A Prospective Cross-Sectional Study.

INTRODUCTION: Sarcopenia is a skeletal muscle disease manifesting as low muscle mass and impaired muscle function. It has been reported that sarcopenia correlates with a low quality of life (QOL) and an increased risk of falls in patients with Parkinson's disease (PD). Nevertheless, few studies have investigated the prevalence, impact, and screening methods of sarcopenia in Japanese patients with PD. METHODS: Sarcopenia was diagnosed based on the Asian Working Group for Sarcopenia 2019 consensus. We compared demographic characteristics, severity of PD, levodopa equivalent daily dose, QOL, fatigue, impulsive and compulsive behaviors, body mass index (BMI), calf circumference, skeletal muscle mass index (SMI), handgrip strength, a 4-meter gait speed, a five-time sit-to-stand test (FTSST), short physical performance battery, and SARC-F questionnaire scores between sarcopenia and non-sarcopenia groups. Furthermore, to investigate the best tool for screening sarcopenia in PD, the sensitivity and specificity of calf circumference, handgrip strength, FTSST, and SARC-F questionnaire were compared. RESULTS: The prevalence of sarcopenia in PD was 31.9% (15/47). The sarcopenia group showed significantly higher age (77.3 ± 5.12 versus 70.3 ± 8.17, p = 0.0042), lower BMI (19.3 ± 2.99 versus 23.3 ± 3.18, p = 0.0002), higher rate of decreased calf circumference (86.6% versus 34.3%, p = 0.0013) and SMI (100% versus 6.25%, p < 0.0001), and worse FTSST (15.5 ± 5.57 versus 12.0 ± 4.12, p = 0.0219). The other parameters were not significantly different. Among screening tools, calf circumference had the highest sensitivity (86%) and specificity (65%). All screening tools had higher sensitivity and specificity in men than in women. The SARC-F questionnaire was not useful in distinguishing sarcopenia but was significantly correlated with the Movement Disorder Society-sponsored revision of the Unified Parkinson's Disease Rating Scale Part 3 (r = 0.41, p = 0.0037) and the 39-item Parkinson's Disease QOL Scale (r = 0.71, p < 0.0001). CONCLUSION: This study investigated the characteristics of PD patients with sarcopenia in Japan. Calf circumference was found to be the most useful tool for screening sarcopenia in PD. Handgrip strength and FTSST also showed high sensitivities, particularly in men. Conversely, the SARC-F questionnaire is not suitable for diagnosing sarcopenia in PD.

[Varicella-zoster virus infection with concomitant lower cranial polyneuropathy in the absence of fever, headache and meningeal signs].

We present varicella-zoster virus (VZV) infection with concomitant lower cranial polyneuropathy in the absence of meningeal symptoms. Physical examination showed involvement of cranial nerves IX and X in Case 1 and of cranial nerves IX, X, and XI in Case 2. Cerebrospinal fluid (CSF) analysis revealed mild lymphocytic pleocytosis, normal protein levels, and absence of VZV-DNA based on polymerase chain reaction (PCR) analysis. Serum anti-VZV antibody testing showed positive results in both cases, which confirmed the diagnosis of VZV infection. VZV infection accompanied by lower cranial polyneuropathy is rare; therefore, it is important to consider VZV reactivation as an etiopathogenetic contributor to pharyngeal palsy and hoarseness. We emphasize the importance of serological analysis for precise diagnosis in VZV infection with multiple lower cranial nerve palsies because the VZV-DNA PCR test may show negative results in patients without meningitis symptoms or in those with normal CSF protein levels.

Acute Oropharyngeal Palsy Following Bilateral Adie's Tonic Pupils Associated with Anti-GT1a and GQ1b IgG Antibodies.

A 36-year-old man was admitted to our hospital with complaints of dysphagia and photophobia. A neurological examination showed oropharyngeal palsy and bilateral mydriasis with loss of light reflexes in the absence of external ophthalmoplegia. Bilateral pupils were supersensitive to pilocarpine 0.1%, which was compatible with Adie's tonic pupils. Serum IgG reacted with GQ1b, GT1a, GalNAc-GD1a, and GD3. Intravenous high-dose immunoglobulin therapy improved his neurological symptoms within three weeks. To our knowledge, there is no medical literature describing acute oropharyngeal palsy with Adie's tonic pupils. We recommend evaluating antiganglioside antibodies to clarify the cause of oropharyngeal palsy and Adie's tonic pupils.

Acute eye movement-retained internal ophthalmoplegia in atypical Miller Fisher syndrome variants are associated with IgG anti-GQ1b antibodies.

Ophthalmoplegia is a common neurological finding in Miller Fisher syndrome (MFS), but acute eye movement-retained internal ophthalmoplegia is a rare variant of MFS. In this report, we present three cases of acute eye movement-retained internal ophthalmoplegia; IgG anti-GQ1b antibodies were detected in all patients. We reviewed a total of 13 cases, including 10 previously reported cases, and revealed that IgG anti-GQ1b antibodies were identified in all but one patient. In addition, we investigated the correlation between acute eye movement-retained internal ophthalmoplegia and antibodies against ganglioside complexes. We found that anti-GQ1b antibodies in our patients reacted with GQ1b or GT1a but not GQ1b/GM1 or GQ1b/GD1a complexes, indicating that antibodies against disialosyl residues have a pathogenetic role in acute eye movement-retained internal ophthalmoplegia. This is the first study describing that acute eye movement-retained internal ophthalmoplegia is associated with IgG antibodies specific to GQ1b or GT1a.

Neurosarcoidosis Mimicking the Recurrence of Malignant Lymphoma.

A 67-year-old woman with a recurrent history of malignant lymphoma (ML) presented with muscle weakness and paresthesia of the fingertips and feet. Due to the elevated level of serum soluble interleukin-2 receptor and increased 18F-fluorodeoxyglucose uptake in a mediastinal lymph node, neurolymphomatosis was initially suspected. Neurological and electrophysiological examinations were consistent with mononeuropathy multiplex. A diagnosis of neurosarcoidosis was made based on the presence of noncaseating epithelioid granulomas in the mediastinal lymph node, along with the presence of the uveitis, cardiac inflammation, and mononeuropathy multiplex. She was treated with glucocorticoids and azathioprine, and her symptoms disappeared. Sarcoidosis following ML is rare, and since biopsy of nervous systems is often improbable, differentiating neurosarcoidosis and neurolymphomatosis can be difficult as their clinical symptoms can be similar. Clinicians should consider systemic pathological investigations based on 18F-fluorodeoxyglucose positron emission tomography examination in addition to comprehensive evaluation to accurately diagnose neurosarcoidosis.

[Acute-onset autoimmune autonomic ganglionopathy remarkably effective in intravenous high-dose immunoglobulin therapy].

A 77-year-old woman developed acute onset of orthostatic hypotension, urinary retention, and constipation. Neurological examination on admission showed severe orthostatic hypotension accompanied by syncope, mydriatic pupils, and attenuation of light reflexes with no abnormalities in other neurological systems. Autonomic testing revealed denervation hypersensitivity in norepinephrine (NE) intravenous infusion test and 0.125% pilocarpine instillation test, low NE in the serum, and decreased amount of sweating in quantitative sudomotor axon reflex test. These findings indicated dysfunction of postganglionic autonomic nerves. Autoimmune autonomic ganglionopathy (AAG) was diagnosed due to the presence of anti-ganglionic acetylcholine receptors. The patient was given intravenous high-dose immunoglobulin therapy (IVIg), improving orthostatic hypotension, urinary retention, and constipation. Previous reports indicated that the response to IVIg varied from case to case. Thus, this case suggests that IVIg is effective in acute-onset AAG cases.

DEC1 negatively regulates the expression of CXCL10 and CCL5 induced by poly IC in normal human mesangial cells.

The functions of differentiated embryonic chondrocyte gene (DEC) 1, a basic helix-loop-helix (bHLH) transcription factor, have been reported to be associated with the regulation of mammalian circadian rhythms, differentiation of chondrocytes and skeletal muscles, apoptosis, hypoxia-induced reactions and epithelial mesenchymal transition. Our previous report showed that another bHLH transcription factor DEC2 constitutes a negative feedback loop in Toll-like receptor 3 (TLR3)/interferon (IFN)-ß-mediated inflammatory responses in human mesangial cells. However, the role of DEC1 in innate immune responses remains unclear. We have previously reported TLR3/IFN-ß/retinoic acid-inducible gene-I (RIG-I)/CCL5 and TLR3/IFN-ß/melanoma differentiation-associated gene 5 (MDA5)/CXCL10 axes in cultured normal human mesangial cells treated with polyinosinic-polycytidylic acid (poly IC), a synthetic double-stranded RNA that is sensed by TLR3. The present study was carried out to examine the involvement of DEC1 in these axes. DEC1 was constitutively expressed in human mesangial cells, and the expression was not altered by treatment with poly IC. Interestingly, RNA interference against DEC1 markedly enhanced the poly IC-induced expression of chemokines CXCL10 and CCL5. Knockdown of DEC1 increased the poly IC-induced MDA5 and RIG-I protein expression without affecting mRNA expression, and did not affect phosphorylation of signal transducer and transcription 1 (STAT1). DEC1 may serve as an anti-inflammatory factor by negative regulation of MDA5/CXCL10 and RIG-I/CCL5 in human mesangial cells treated with poly IC.

DEC1 promotes hypoxia-induced epithelial-mesenchymal transition (EMT) in human hepatocellular carcinoma cells.

Differentiated embryonic chondrocyte (DEC) 1 has been reported to be involved in cell differentiation, hypoxia response, and cancer progression. Recent studies have demonstrated that hypoxia-inducible factor (HIF)-1α induces epithelial-mesenchymal transition (EMT) in carcinoma cells to facilitate cell invasiveness and metastasis. However, it remains unclear whether DEC1 participates in hypoxia-mediated EMT processes. In the present study, we reported that hypoxia induced DEC1 expression in hepatocellular carcinoma (HCC) HepG2 cells, and DEC1 negatively regulated expression of HIF-1α and E-cadherin in transcriptional/translational levels. Cell morphological changes were evaluated with hematoxylin and eosin (H-E) staining. Exposure to hypoxia caused spindle-like shape in some of the HepG2 cells, and DEC1 overexpression furthered these changes. In conclusions, DEC1 is involved in hypoxia-induced EMT processes via negatively regulating E-cadherin expression in HepG2 cells.

MDA5 and ISG56 mediate CXCL10 expression induced by toll-like receptor 4 activation in U373MG human astrocytoma cells.

Toll-like receptor (TLR) 4 is a pattern recognition receptor, and recognizes not only bacterial lipopolysaccharide (LPS) but also endogenous danger-associated molecular patterns released from dying or injured cells. It has been reported that TLR4 signaling in astrocytes plays an important role in various neurological diseases. However, details of TLR4 signaling in astrocytes are not fully elucidated. In the present study, we demonstrated that TLR4 signaling, induced by LPS, increases the expression of melanoma differentiation-associated gene 5 (MDA5) and interferon (IFN)-stimulated gene 56 (ISG56) in U373MG human astrocytoma cells. We also found that nuclear factor-κB, p38 mitogen-activated protein kinase and IFN-ß are involved in the expression of MDA5 and ISG56 induced by LPS. RNA interference experiments revealed that MDA5 and ISG56 positively regulate the LPS-induced expression of a chemokine CXCL10, but not CCL2. In addition, it was suggested that MDA5 and ISG56 constitute a positive feedback loop. These results suggest that MDA5 and ISG56 may contribute not only to physiological inflammatory reactions but also to the pathogenesis of various neurological diseases elicited by TLR4 in astrocytes, at least in part, by regulating the expression of CXCL10.