Case of liver tuberculosis requiring differentiation from liver metastasis of cancer

A 79-year-old woman was admitted to our hospital because of general fatigue. Chest radiograph and computed tomograph showed bronchiectasis and centrilobular nodules in the right middle lobe and lingula, which had not changed from previous examination. Intrahepatic nodular lesions and swelling of the left cervical lymph nodes, supraclavicular lymph node, abdominal paraaortic lymph nodes and inguinal lymph nodes was observed. Biopsy specimen of the liver lesion demonstrated epithelioid cell granulomas. Biopsy of the right inguinal lymph node demonstrated epithelioid cell granulomas with caseous necrosis and culture of the specimen showed Mycobacterium tuberculosis. The patient was diagnosed as having liver tuberculosis and multiple tuberculous lymphadenitis. Antituberculous treatment with isoniazid, rifampicin, ethambutol and pyrazinamide were started and continued for 6 months. All lesions improved after treatment. This was a rare case of liver tuberculosis that was difficult to distinguish from liver metastasis of cancer.     

Optimal therapeutic concentration of tacrolimus in adult patients undergoing reduced-intensity cord blood transplantation

To investigate the effectiveness and safety of GVHD prophylaxis using FK506 alone as a continuous infusion, 104 patients who underwent reduced-intensity cord blood transplantation were retrospectively reviewed. The respective incidence of acute GVHD was 25 grade 1(24. 1%), 19 grade2(18. 3%), 15 grade3(14. 4%), and 4 grade4(3. 8%), which are comparable to that in the literature. The incidences of grade 2 and greater acute GVHD were 32 out of 69(46. 4%)for those whose wholeblood concentration of FK506 werele ss than 13 ng/mL, whereas 6 out of 35(17. 1%)for those FK5 06 were greater than 13 ng/mL. The differenceies between above and below 13 ng/mL were statistically significant(p=0. 008). There were 19 cases(18. 3%)of renal dysfunction, although none required hemodialysis. There were only 4 patients who discontinued FK506, which further confirmed the safety of FK506 alone. Together with our previous report on the upper limit of FK506(17 ng/mL)and these results, we recommend the optimal serum concentration of FK506 to range from 13 to 17 ng/ mL.     

Comparison of late post-operative cardiopulmonary responses in the Fontan versus ventricular septation for double-inlet left ventricular repair

Ventricular septation (VS) and the Fontan procedure are alternatives for definitive repair in patients with double-inlet left ventricle; although VS is theoretically preferable, the current preference in practice is the Fontan procedure. However, the long-term outcomes of both procedures remain unclear. To address this issue, cardiopulmonary responses during exercise were measured in patients with double-inlet left ventricle, and the impact of the type of procedure performed, Fontan or VS, on long-term exercise capacity and late postoperative clinical profiles was assessed. Fourteen post-Fontan patients (mean age 17+/-6 years) and 13 VS patients (mean age 19+/-4 years) underwent exercise testing. Of the 13 VS patients, 5 required atrioventricular valve replacement (AVVR), and 7 required pacemaker implantation. Although no difference in peak oxygen uptake was found between the VS and Fontan patients, peak oxygen uptake was higher in VS patients without AVVR (30+/-8 ml/kg/min) than in VS patients with AVVR (19+/-1 ml/kg/min) and Fontan patients (22+/-6 ml/kg/min) (p<0.01). There was no significant difference in peak oxygen uptake between the VS patients with and without pacemaker implantation (p=0.09). The clinical profiles of the VS and Fontan patients were similar in terms of medication and freedom from tachyarrhythmias or reoperations during the follow-up period. In conclusion, the data suggest that VS without AVVR provides excellent future exercise capacity in selected patients with double-inlet left ventricle.     

Monitoring neutrophil engraftment in allogeneic stem cell transplantation by flow cytometric analysis of neutrophil-specific antigens NA1 and NA2

Neutrophil-specific antigen (NA) expression on neutrophils was analysed in 18 Japanese children before and after allogeneic stem cell transplantation (allo-SCT) with myeloablative regimen. Donor-recipient NA-incompatibility was present in one of eight NA1/NA2 heterozygous patients and eight of 10 NA1/NA1 or NA2/NA2 homozygous patients. After allo-SCTs from NA-incompatible donors, a neutrophil recipient-to-donor conversion was confirmed in all cases. Conversion to donor NA type was complete before the absolute neutrophil count reached 0.1 x 10(9)/l. These observations indicate that flow cytometric analysis of NA antigens is a simple and useful method for monitoring neutrophil engraftment in NA-incompatible allo-SCT.     

A suspected case of voriconazole-induced lung injury]

A 71-year-old man was initially given a diagnosis of pulmonary nontuberculous mycobacterial infection due to Mycobacterium intracellulare (M. intracellulare). The patient was admitted because chest roentgenogram and CT scanning showed a progression of infiltrating shadows in the bilateral upper lung fields. Aspergillus fumigatus was identified by bronchial lavage. The patient was found to have chronic necrotizing pulmonary aspergillosis with M. intracellulare and treated with voriconazole (VRCZ). After fifteen days of treatment, he complained of dyspnea and cough. A chest CT showed new diffuse ground glass opacity in the left lower lobe. Arterial blood gas analysis demonstrated severe hypoxemia. Due to concerns about drug-induced lung injury, voriconazole was discontinued and corticosteroid therapy was started. VRCZ was replaced by micafungin. Thereafter, symptoms and left lower shadows resolved. Although the lymphocyte stimulation test for voriconazole was negative, we considered that this pulmonary lesion may have been an adverse reaction to voriconazole.     

Mushroom toxins: a forensic toxicological review

Mushrooms are ubiquitous in the world. Amateur hunters harvest mushrooms growing in forests to enjoy eating them as seasonal delicacies, and occasionally they cause poisonings and even deaths. In this review, mushroom toxins are tabulated according to mushroom species, symptoms, toxicities and analytical methods on the basis of references. Second, because we constructed a method for analysis of amatoxins, the most virulent mushroom toxins, by liquid chromatography-time-of-flight-mass spectrometry, we introduce it for use in forensic toxicology. Third, an extensive poisoning incident after consumption of the usually edible mushroom Pleurocybella porrigens took place in nine prefectures in Japan from September to December 2004, resulting in 59 poisoned people including 19 deaths; this incident is briefly described and discussed in relation to its causative toxin(s). Finally, we present the chemical structures of new toxins purified from the highly toxic mushrooms Podostroma cornu-damae and Russula subnigricans; their structures were very unique, and the toxicities were comparable to those of amatoxins. From the forensic toxicological point of view, reports on sophisticated methodology for analyses of mushroom toxins seem to be too scant even for the well-known toxins. Hereafter, a number of toxic mushrooms and their new toxins are expected to be disclosed, especially because of environmental changes such as the global warming phenomenon.     

Efficacy and Safety of Tunneled Pleural Catheters in Adults with Malignant Pleural Effusions: A Systematic Review

Background  

Malignant pleural effusions (MPE) are a frequent cause of dyspnea and discomfort at the end of cancer patients' lives. The tunneled indwelling pleural catheter (TIPC) was approved by the FDA in 1997 and has been investigated as a treatment for MPE.     

An ambiguous pedigree of facioscapulohumeral muscular dystrophy which showed double EcoRI/BlnI resistant short fragments]

We report a facioscapulohumeral muscular dystrophy (FSHD) pedigree having double short (25 kb and 33 kb) BlnI resistant (4 q-like) fragments. Two of three male siblings developed shoulder-girdle weakness and minimum facial involvement from their adolescence. Although the rest (third) brother had non-progressive hemi-palsy in face and upper-extremity and strabismus caused by birth trauma, he had no clinical symptoms of FSHD. Mother presented mild shoulder weakness after cholecystectomy at the age of 50 years, but with no facial involvement and normal serum creatine kinase (CK) level (45 IU/L). On the contrary, father had high CK level (450 IU/L) despite no neurological abnormalities. After EcoRI/BlnI double digestion, two short fragments were detected in the two affected siblings. Then, all family members were examined to determine pathognomonic fragment. Consequently, mother (25 kb and 90 kb) and the third non-affected brother (25 kb and 51 kb) had two 4 q-like fragments, however, three 4 q-like fragments were detected in father (33 kb, 51 kb and 130 kb), proband (25 kb, 33 kb and 130 kb) and affected brother (25 kb, 33 kb and 51 kb). These findings revealed that the 4 q-like 33 kb fragment actually located on 10q26 through inter-chromosomal exchange. Thus the 25 kb fragment inherited from mother was determined as co-segregating with the disease. To ensure genetic diagnosis for FSHD, investigation of family members is surely required.