Case of bladder tuberculosis with onset at the age of nineteen--treatment of urinary tract tuberculosis in accordance with the new Japanese Tuberculosis Treatment Guidelines

A 24-year-old man experienced gross haematuria and dysuria several times a year from the age of 19, presenting to this Department for the first time at age 21, when he was given standard antibiotic treatment for acute cystitis. Although urinary symptoms persisted, he failed to attend for follow-up. He attended another clinic at the age of 24 with increased urinary frequency. Transrectal ultrasonography revealed thickening of the bladder wall, concavity of the right bladder neck, and nodular changes extending from the left bladder neck to the left bladder wall, so he was referred to this department for further investigation. Mycobacterium tuberculosis was detected in the urine by the referring doctor, so the diagnosis was made of bladder tuberculosis (TB). We treated him with rifampicin (RFP), isoniazid (INH) and pyrazinamide (PZA) triple therapy for 2 months, followed by RFP and INH dual therapy for 4 months. His urinary frequency improved markedly after one month, and his bladder capacity was 420 ml after 4 months of treatment. After 2 and half year follow-up he remains well without any signs of relapse. To our knowledge, this is only the ninth case of teenage onset of urinary tract TB in Japan since 1995. As specified in Clause 22 of the Enforcement Regulations of the Tuberculosis Control Law, chemotherapy and surgical treatment of TB, the mainstays of treatment, should be administered in accordance with the 'Standards for the Treatment of Tuberculosis', issued by the Japanese Minister of Health and revised in 2004. The level of recognition of the 'Standards for the Treatment of Tuberculosis' is low, however. Although the incidence of TB of the urinary tract has dropped dramatically, as urologists we must be aware that treatment of this condition must be given in accordance with the Standards.     

Giant morgagni hernia causing cardiac tamponade

A 57-year-old man presented with worsening symptoms of shortness of breath and chest pain. He was found to have a giant Morgagni hernia with severe compression of his right ventricle on computed tomography scan. The hernia which contained greater omentum, small intestine and transverse colon was urgently repaired through a median sternotomy and laparotomy with a polypropylene mesh. Morgagni hernia is a type of congenital diaphragmatic hernia, which may not be symptomatic until adulthood. Presentation with this degree of right ventricular compression is rare.     

Autoantibodies to cyclic citrullinated peptide 2 (CCP2) are superior to other potential diagnostic biomarkers for predicting rheumatoid arthritis in early undifferentiated arthritis

We evaluated the diagnostic value of anti-cyclic citrullinated peptide 2 (anti-CCP2) antibodies and other potential diagnostic biomarkers (IgM rheumatoid factor, anti-agalactosyl IgG antibodies, matrix metalloproteinase 3, C-reactive protein) for predicting early development of rheumatoid arthritis (RA). Patients were defined as having recent-onset undifferentiated arthritis (UA) if they had developed arthritis in two or more joints within the previous 2 years and could not be classified with a well-defined arthropathy. Baseline levels of biomarkers were measured in blood samples collected at the entry of the study and the patients were followed for 1 year to monitor development of RA. Diagnoses of RA and non-RA arthropathies were made according to individual standard diagnostic criteria. A total of 146 patients were enrolled in the study. In the follow-up year, 18 patients developed RA, 54 developed non-RA arthropathies, and 60 remained in the UA category. The sensitivity and specificity of the presence of anti-CCP2 antibodies for the diagnosis of RA were 83.3 and 93.0%, respectively. The positive predictive value (PPV), negative predictive value (NPV), and diagnostic accuracy of anti-CCP2 antibodies for RA (65.2, 97.2, and 91.7%, respectively) were higher than for any other biomarker. Combination of anti-CCP2 with any other biomarker only slightly improved each diagnostic value compared to the presence of anti-CCP2 alone. Among the anti-CCP2-positive patients, the average titer was significantly higher in those with RA than in non-RA or UA patients (163.7 +/- 138.4 vs 55.2 +/- 72.0 U/ml, p = 0.017). Anti-CCP2 antibodies are superior to any other single biomarker for predicting early development of RA in patients with recent-onset UA and the diagnostic value of anti-CCP2 alone is similar to that for biomarker combinations. Moreover, the anti-CCP2 antibody titer is useful to discriminate between patients at high risk for early developing RA from those at risk of developing non-RA arthropathies.     

Helicobacter pylori, chronic atrophic gastritis, inactive aldehyde dehydrogenase-2, macrocytosis and multiple upper aerodigestive tract cancers and the risk for gastric cancer in alcoholic Japanese men

BACKGROUND: Gastric carcinoma occurs at a high rate in alcoholic Japanese men. Inactive heterozygous aldehyde dehydrogenase-2 (ALDH2*1/2*2) and macrocytosis (mean corpuscular volume [MCV] > or = 106 fl) enhance the risk for esophageal carcinoma, which frequently occurs with gastric carcinoma in this population. Whether alcoholism affects Helicobacter pylori-induced chronic atrophic gastritis (CAG) is unknown. METHODS: This study of Japanese alcoholic men with (n = 45) and without (n = 281) gastric carcinoma included assessment of H. pylori IgG antibody, serum pepsinogen-confirmed CAG, MCV, and ALDH2 genotype. RESULTS: The gastric carcinoma cases had a significantly higher age-adjusted prevalence of H. pylori-positivity (78%vs 57%), CAG (78%vs 42%), ALDH2*1/2*2 (36%vs 14%), MCV > or =106 fl (38%vs 20%), and concurrent esophageal/oropharyngolaryngeal carcinoma (18%vs 5%) than controls. Among gastric cancer-free controls, the prevalence of CAG was higher than generally reported in Japan, regardless of H. pylori status (H. pylori-positive, 56%vs 35-36% for Japanese general population; H. pylori-negative, 8%vs 1-3%). Alcoholism may accelerate the progression of CAG. Each of these factors increased the risk of gastric carcinoma (OR(s) = 3.7 for H. pylori-positive, 2.7 for non-severe CAG, 8.7 for severe CAG, 3.5 for ALDH2*1/2*2, 2.5 for MCV > or =106 fl, and 3.7 for concurrent carcinoma). A multivariate analysis showed that CAG and ALDH2*1/2*2 were independently related to the risk of gastric carcinoma. Combinations of CAG and ALDH2*1/2*2 showed greater risks of gastric carcinoma (OR(s) = 4.0 for non-severe CAG alone, 17.6 for severe CAG alone, 9.7 for ALDH2*1/2*2 alone, 17.1 for non-severe CAG plus ALDH2*1/2*2, and 39.2 for severe CAG plus ALDH2*1/2*2). CONCLUSIONS: Combining blood tests for H. pylori, CAG, MCV and ALDH2 genotype could offer a new means of predicting risk of gastric carcinoma in Japanese alcoholic men.     

Successful wound management for infected perineum in recurrent rectal cancer by a two-step operation using muscle flaps: a case report

Perineal wound failure associated with infection is one of the intractable complications after abdominoperineal resection including pelvic exenteration. It is supposed that there is a strong possibility of this complication occurring in patients with infected perineal lesions after radiation therapy. We describe herein a case of a 56-year-old female who received pelvic exenteration for recurrent rectal cancer, the perineal wound of whom was successfully managed by a two-step operation using muscle flaps. The patient had a recurrent tumor in her pelvis after abdominoperineal resection for locally advanced rectal cancer. She had been treated with chemoradiotherapy for the recurrent tumor. The tumor was exposed to the perineum and was associated with bacterial infection. The tumor was curatively resected by total pelvic exenteration. The perineal wound infection was controlled by a lay-open method after reconstruction of the pelvic floor using a rectus abdominis muscle. The perineal wound was secondarily closed using gracilis mycocutaneous flaps 14 days after pelvic exenteration. She was discharged uneventfully 14 days after perineal closure. The strategy in the present report may be a useful option for perineal wound management in patients with a high risk of perineal wound failure due to infection after abdominoperineal resection.     

Severe hemorrhagic complications during remission induction therapy for acute promyelocytic leukemia: incidence, risk factors, and influence on outcome

BACKGROUND: Even after the introduction of all-trans retinoic acid (ATRA), early hemorrhagic death remains a major cause of remission induction failure for acute promyelocytic leukemia (APL). METHODS: To investigate severe hemorrhagic complications during remission induction therapy with respect to incidence, risk factors, and influence on outcome. Results were analyzed for 279 patients enrolled in the APL97 study conducted by the Japan Adult Leukemia Study Group (JALSG). RESULTS: Severe hemorrhage occurred in 18 patients (6.5%). Although most of them were receiving frequent transfusions, the targeted levels of platelet counts (30 x 10(9)/L) and plasma fibrinogen (1.5 g/L) for this study were reached at the day of bleeding in only 71% and 40%, respectively. Nine of them succumbed to an early death, while the remaining nine patients eventually achieved complete remission (CR). The 5-yr event-free survival rate was 68.1% for those who did not suffer severe hemorrhage, and 31.1% for those who did (P < 0.0001). For patients who achieved CR, on the other hand, there was no difference in disease-free survival between patients with and without severe hemorrhage (P = 0.6043). Risk factor analysis identified three pretreatment variables associated with severe hemorrhage: initial fibrinogen level, white blood cell count, and performance status. Additionally, patients with severe hemorrhage were more easily prone to develop retinoic acid syndrome or pneumonia than patients without hemorrhage. CONCLUSIONS: These results indicate that fatal hemorrhage represents a major obstacle in curing APL, and that patients with such high-risk features may benefit from more aggressive supportive care.