Soft Palate Movement During Sucking Behavior

To clarify the aspects and role of oropharyngeal closure, soft palate movements during sucking were observed and then assessed by electromyographic and fluoroscopic analyses. Three patterns of sucking movements by the palatoglossus and levator veli palatini muscles were analyzed with electromyographic means in seven healthy adults. Furthermore, a forced sucking maneuver, which required special effort to produce a strong sucking pressure by opening the jaw, was analyzed using lateral fluoroscopy in three of the subjects. During all tested sucking movements, the palatoglossus muscle showed continuous activity. The levator veli palatini muscle did not show remarkable activity during regular air sucking or water sucking when water was held in the oral cavity. However, its participation increased when intraoral sucking pressure was increased by opening the jaw, and lateral fluoroscopic examinations revealed that the soft palate was pulled toward the oral cavity to form a tight contact between the rostral portion of the soft palate and the retrotongue, causing the soft palate to make an L shape. The palatoglossus muscle plays a major role in palatal movement during sucking. Furthermore, the levator veli palatini muscle, whose activity was observed only during high-pressure sucking with an open jaw, may act to maintain tension in the soft palate against strong negative pressure in the oral cavity.     

Hepatocellular Carcinoma Metastatic to the Stomach Presenting as Bleeding Multiple Craterogenic Ulcers

A patient with previous resection of primary hepatocellular carcinoma developed upper intestinal bleeding. Pinch biopsy and needle aspiration biopsy of a submucosal antral lesion seen at endoscopy yielded metastatic hepatoma. We believe this to be the first report of the endoscopic appearance of a submucosal tumor. Currently available methods of tissue diagnosis are discussed.     

Histoplasmosis in a child with JRA on low-dose methotrexate

SIR, Patients receiving immunosuppressive agents are at riskfor opportunistic infections (OIs), highlighted by recent reportsof tuberculous and fungal infections in patients receiving anti-TNFtherapy. OIs are rare in children receiving low-dose methotrexate,despite its frequent use in the management of rheumatologicalconditions. We present a case of histoplasmosis in a child withpolyarticular juvenile rheumatoid arthritis (JRA) receivinglow-dose methotrexate. A 7-yr-old Missouri female presented with diffuse joint complaintsand morning stiffness. She had synovitis with decreased rangeof motion in     

Histoplasmosis in patients with the acquired immune deficiency syndrome

Five patients with disseminated histoplasmosis are reviewed. Four of five had the acquired immune deficiency syndrome (AIDS) and one was receiving steroid therapy. All were immigrants to the United States from Puerto Rico, the Dominican Republic, or South America, and none had a history of travel to regions of the United States where Histoplasma is endemic. Histoplasma complement fixation titers to mycelial antigen were not demonstrable in three of three patients in whom they were measured. Of the four patients with AIDS, Histoplasma capsulatum was isolated from bone marrow aspirates in two patients and from lymph node and liver biopsy specimens in one patient each. One of the bone marrow specimens showed organisms on Gomori-methenamine silver stain. In the other three cases, results of staining were falsely negative and diagnosis awaited culture results weeks later. Amphotericin B therapy resulted in rapid clinical improvement in the three patients that were treated. Intravenous therapy was followed by treatment with oral ketoconazole. Follow-up has not been long enough to determine the ultimate efficacy of ketoconazole. Disseminated histoplasmosis should be considered in all patients from the Caribbean or South America with AIDS or who are receiving immunosuppressive therapy.     

Disseminated Histoplasmosis Presenting as Weight Loss and Hypercalcemia in a Renal Transplant Patient With Prior History of Subtotal Parathyroidectomy

Hypercalcemia and weight loss in a renal transplant patient especially with history of parathyroidectomy raises concern for an underlying malignancy, fungal infections or granulomatous disease. We present a case of 45-year-old male with history of subtotal parathyroidectomy presented with severe persistent hypercalcemia, acute kidney injury (AKI) and significant weight loss. An extensive workup revealed disseminated histoplasmosis. Hypercalcemia (which was refractory to initial medical management) and other symptoms resolved after a few weeks of initiating the antifungal treatment.     

Gastritis and Acid Secretion in Patients with Gastric Ulcers and Duodenal Ulcers

Background: The aim of this study was to clarify whether the results of surgical treatment of ruptured hepatocellular carcinoma (HCC) are poorer than the results of surgical treatment of non‐ruptured HCC. Methods: Out of a total of 224 HCC patients, the 6 patients with ruptured HCC were compared with 15 patients with non‐ruptured HCC based on TNM stage IVA and having a Cancer of the Liver Italian Program (CLIP) score of 1 or 2. Results: There were no significant differences in clinical and pathological features between the two groups. The 1‐year and 3‐year overall survival rates were 69.3% and 21.2%, respectively, in the ruptured HCC group and 51.3% and 20.5%, respectively, in the non‐ruptured HCC group. The 1‐year and 3‐year disease‐free survival rates were 33.0% and 0%, respectively, in the ruptured HCC group and 38.9% and 15.6%, respectively, in the non‐ruptured HCC group. The differences in survival rates between these two groups did not reach statistical significance. Conclusion: Hepatic resection as definitive treatment after recovery from the initial insult of the rupture of HCC yields results similar to those obtained by surgical treatment of non‐ruptured HCC at the same tumor stage and with the same degree of liver damage.     

Adult Scurvy Presenting with Painful Purpura on the Legs

Prolonged vitamin C deficiency can result in numerous metabolic abnormalities like impaired tissue repair and defective collagen synthesis. This case report describes a middle-age Japanese man presenting painful purpura on his lower limbs, severe anemia, and altered consciousness. The patient had been eating a selective diet lacking in vegetables and fruits since childhood. A serum analysis demonstrated a low level of vitamin C. The patient was treated with vitamin supplementation and psychological intervention. Scurvy is an under-considered illness with a favorable prognosis if diagnosed early while it is still sporadically encountered in some patients with malabsorption or malnutrition even in modern times.     

RE: Histoplasmosis in a child with JRA on low-dose methotrexate

SIR, We appreciate the comments of Kleiman et al., which serveto     

Histoplasmosis after treatment with anti-tumor necrosis factor-alpha therapy

Anti-tumor necrosis factor-alpha (TNF-alpha) antibodies are frequently used to treat inflammatory diseases. However, these drugs also have immunosuppressive effects. We report on three patients who developed disseminated histoplasmosis on therapy with TNF-alpha inhibitors. In vitro assays were used to characterize the role of these agents in host defense against Histoplasma capsulatum. Intracellular proliferation of H. capsulatum was measured in alveolar macrophages and peripheral monocytes of normal volunteers in the presence and absence of the TNF-alpha antibody, infliximab. Both infliximab and control antibody enhanced fungal growth in monocytes and alveolar macrophages, suggesting this was a nonspecific antibody response. Despite similar intracellular fungal loads in the presence of both antibodies, lymphocyte proliferation in response to blood monocytes and alveolar macrophages infected with H. capsulatum was inhibited by the addition of physiologic doses of infliximab, whereas control antibody had no effect. The production of H. capsulatum-induced interferon-gamma and TNF-alpha was assessed in 5-day cultures containing lymphocytes and alveolar macrophages or monocytes. Interferon-gamma secretion was significantly reduced in the presence of infliximab. In summary, patients receiving anti-TNF-alpha therapy are at risk for developing disseminated histoplasmosis. This may be due to a defect in the TH1 arm of cellular immunity.