Delayed motor and sensory neuropathy in a patient with brainstem encephalitis

Bickerstaff's brainstem encephalitis (BBE), Miller Fisher syndrome (MFS) and Guillain-Barré syndrome (GBS) are thought to be closely related and to form a continuous spectrum. However, chronic polyneuropathy in BBE has not been reported. We report the temporal profile of anti-ganglioside antibody titer in a case of BBE-like brainstem encephalitis complicated with chronic polyneuropathy. A 71-year-old Japanese woman presented with drowsiness and cerebellar ataxia in addition to mild weakness in distal limb muscles. Anti-GalNAc-GD1a IgG and anti-GalNAc-GM1b IgG antibodies were positive in her serum. Brain magnetic resonance imaging revealed high-intensity signals in the midbrain, pons, and middle cerebellar peduncles on T2-weighted images. Central nervous system manifestations improved after immunomodulating therapy that included prednisolone, plasmapheresis and intravenous immunoglobulin. Nevertheless, the distal muscle weakness was exacerbated when the anti-GalNAc-GD1a IgG titer was elevated. Nerve conduction study indicated motor and sensory neuropathy which was developed motor dominant axonal damage. These findings suggest that anti-ganglioside antibodies, including anti-GalNAc-GD1a IgG, may be involved in a common autoimmune mechanism in BBE-like brainstem encephalitis and chronic motor dominant axonal neuropathy. However, the fact that the latter manifestation exacerbated after the improvement of former one possibly indicates different thresholds of neurologic symptoms mediated by anti-ganglioside antibodies in the present patient.     

Histological changes in the rabbit kidney induced by transarterial injection of a hypertonic sodium chloride solution

PURPOSE: To evaluate histological changes in normal renal tissue induced by the injection of a hypertonic liquid. MATERIALS AND METHODS: Transarterial injection was performed in 17 healthy rabbits at various rates of infusion and amounts of isotonic and hypertonic (7%) sodium chloride solutions. In group 1, 10 cc of isotonic sodium chloride solution was injected. In groups 2 and 3, 1-10 cc of hypertonic solution was injected at rates of 1.0 cc/sec and 0.05 cc/sec, respectively. After 20 minutes of hemostasis, renal weight measurements and histological examinations were performed. In three rabbits that received 10 cc of 7% sodium chloride, lung samples were also obtained, and histological changes were reviewed. RESULTS: There was no tissue injury in group 1, and in groups 2 and 3 the histological changes for infusions of 4-10 cc were greater than those of 1-3 cc. There was no vascular endothelial cell damage in any case. None of the histological changes were dose dependent, and the lungs showed no clear histological alterations. CONCLUSION: Higher doses of a hypertonic sodium chloride solution cause irreversible histological changes in the rabbit kidney.     

A comparison of perioperative factors with two methods of coronary artery bypass grafting (CABG): off-pump and conventional

BACKGROUND: The safety and efficiency of off-pump coronary artery bypass grafting (OPCAB) are still controversial. The purpose of this study was to evaluate this approach in comparison with the conventional cardiopulmonary bypass technique (cCABG). METHODS: A retrospective review of patients who had undergone coronary artery bypass grafting independently without other operations between January 1, 1999 and September 30, 2001 was performed. The patients were divided into two groups: those who underwent OPCAB and the remainder for cCABG. The perioperative factors of the two groups were compared. RESULTS: A total of 152 OPCAB and 142 cCABG cases were reviewed. Compared with cCABG, OPCAB significantly reduced the amount of catecholamine needed on admission to ICU, intubation time, overall hospital length of stay, and neurologic events. There were also trends for decreases in ICU length of stay, mortality, and renal failure. On the other hand, OPCAB did not affect perioperative blood loss. CONCLUSIONS: Overall OPCAB is safer and more efficient than cCABG. However, we have to note in anesthetic management that OPCAB does not reduce blood loss.     

Impaired vascular endothelium-dependent relaxation in Henoch-Schönlein purpura

Few reports have focused on vascular endothelial function in children with Henoch-Schönlein purpura (HSP). The purpose of the present study was to assess endothelial function and to follow serial changes from the acute to convalescent phases in children with HSP. Forearm flow-mediated vasodilation was evaluated in 21 patients with HSP, aged 4.0–10.3 years (median 6.2 years), and in 14 control subjects. Vascular dimension, mean velocity, and flow volume were measured by ultrasonography in brachial artery before and after hyperemia, and during incremental infusions of nitroglycerin (0.5, 1.0 g/kg per min). In the controls, significant increases in dimension, mean velocity, and flow volume were observed in reactive hyperemia (P<0.01). In contrast, patients in the acute phase of HSP showed a flow velocity profile indicating a highly resistant forearm circulation, and significantly attenuated responses after hyperemia (P<0.01 vs. control), whereas the responses to nitroglycerin were well preserved. In addition, the impaired hyperemic responses recovered in the convalescent phase, with no significant differences compared with controls. These results clearly suggest that forearm vascular endothelium-dependent relaxation was attenuated in patients with acute HSP.     

Proximal-type epithelioid sarcoma in a 36-year-old man: closer immunoelectron-microscopic resemblance of the tumor cells to epithelial cells than to mesenchymal cells

Proximal-type epithelioid sarcoma (PES) is a rare neoplasm. We report a case of PES that arose in the perineal subcutis of a 36-year-old Japanese man who died within 4 months of the first clinical sign, probably due to massive pulmonary metastases. In the present study, we analyzed the tumor obtained at surgery, immunohistochemically, immunoelectron-microscopically and genetically. Although the tumor cells in the patient expressed both cytokeratin and vimentin immunohistochemically, they showed epithelial characteristics immunoelectron-microscopically because they had tonofilaments constructed of cytokeratin, not vimentin. In addition, the cytokeratins expressed on the tumor were glandular-type keratins. These findings indicate that PES may be a form of carcinoma in soft tissue. To ascertain the possible origin of the tumor, we compared the tumor immunohistochemically with fetal tissues. Although notochord and fetal peritoneal mesothelium were similar to the tumor antigenically, we could not confirm the specific origin of the tumor. Furthermore, the p53-WAF1 pathway did not contribute to tumorigenesis in the patient because the tumor had no mutation in exons 5-8 of the p53 gene and was immunohistochemically positive for WAF1.     

Retrospective analysis of concurrent chemoradiation with the combination of bleomycin, ifosfamide and cisplatin (BIP) for uterine cervical cancer

Combination chemotherapy consisting of bleomycin, ifosfamide, and ciplatin (BIP) is recognized as one of the most effective chemotherapies for uterine cervical cancer. However, there have been no reports that evaluate concurrent use of radiation with BIP. The objective of this study was to evaluate the toxicity and response of the combination of BIP concurrent with radiation in patients with squamous cell carcinoma of the uterine cervix. Eligibility criteria included patients who underwent radical hysterectomy (Type III hysterectomy) as a primary treatment and revealed lymph node metastases or deep myometrial invasion (stage IB and IIA) and patients who were previously untreated (stage IIB-IV). All of the patients had biopsy-proven squamous cell carcinoma of the uterine cervix. The patients received three courses of BIP chemoradiation, and the response and toxicity were evaluated. From January 2000 to December 2003, 30 patients met study eligibility criteria. All but three patients completed 3 courses of planned chemotherapy. The frequency of severe (grade 3 and 4) toxicity was as follows: anemia, 46.7%; neutrocytopenia, 73.3%; thrombocytopenia, 16.7%; and nausea and vomiting, 23.3%. Among 30 patients, 22 cases were evaluated for response. Complete response was achieved in 16 (72.7%) of patients, with a response rate of 90.9%. In conclusion, BIP chemoradiation seems to be superior to previously reported chemoradiation regimens, and has a potential as an optimal combination chemotherapy concurrent with radiation.     

Small lung tumors with the size of 1cm or less in diameter: clinical, radiological, and histopathological characteristics

BACKGROUND: The detection rate of small nodules in the peripheral lung area is increasing due to the widespread use of CT scanning. However, the radiological and pathological characteristics of very small tumors have not been fully investigated. METHODS: We evaluated 44 lung tumors with the size of 1cm or less in diameter resected from 38 patients (19 men and 19 women, with an average of 62 years) from 1997 through 2001. The clinical records, the findings of high-resolution CT (HRCT) and histopathological features of resected specimens were analyzed. Adenocarcinoma was histologically further subclassified into types A to F according to the Noguchi's classification. RESULTS: Lobectomy was performed in 20 patients, wedge resection in 15 and segmentectomy in 3, respectively. Thirty-two tumors were adenocarcinomas, 4 were squamous cell carcinomas, and eight were atypical adenomatous hyperplasia (AAH), respectively. All carcinoma cases were proved to be stage IA. In adenocarcinoma, type A was detected in 12 tumors, type B in 13, type C in 1, type D in 2, type E in 1, and type F in 3, respectively. Most of AAH and type A showed pure ground-glass attenuation on HRCT scan, whereas types B to F as well as squamous cell carcinoma frequently had malignant CT signs such as lobulation and convergence of peripheral vessels. Lymphatic or vascular invasion was observed in two adenocarcinomas (types D and F) and two squamous cell carcinomas, and HRCT scan of these four tumors showed soft-tissue attenuation occupying more than two-thirds of each nodule. All patients are currently alive without signs of recurrence after a mean follow-up period of 35.5 months. CONCLUSION: Types A and B of adenocarcinoma were the most common histologic types among lung tumors with the size of 1cm or less in diameter. Limited lung resection appears to be an adequate for such small lung tumors in which soft-tissue attenuation consists of less than two-thirds of the nodule on HRCT.