Chronic contained rupture of an abdominal aortic aneurysm mimicking a retroperitoneal tumor

Chronic contained rupture of an abdominal aortic aneurysm (AAA) is a rare event that is difficult to diagnose due to the atypical and chronic symptoms. We report a case of chronic contained rupture of AAA mimicking a retroperitoneal tumor in a 36-year-old man. The patient presented with weight loss and chronic lower abdominal pain, and was referred to our clinic with a suspected retroperitoneal tumor. Abdominal computed tomography (CT) revealed a distinct mass measuring 15 x 10 x 10 cm in the left retroperitoneal space, involving the abdominal aorta. One week later he experienced sudden abdominal pain radiating to the back. He was subsequently diagnosed with ruptured AAA and aortic dissection. The patient received implantations of both common iliac arteries to the abdominal aorta using Y-grafts and an ascending-to-descending aortic graft in a two-stage operation. His recovery from surgery was uneventful.     

Acute endocapillary proliferative glomerulonephritis associated with human parvovirus B19 infection

A 36-year-old female developed acute nephritic syndrome associated with human parvovirus B19 (HPVB19) infection. Laboratory data showed proteinuria, hypocomplementemia, mild pancytopenia, the presence of immunoglobulin (Ig) M and IgG antibodies to HPVB 19 and positive reaction of serum HPVB19 DNA using a polymerase chain reaction (PCR). A renal biopsy showed endocapillary hypercellularity mainly of mononuclear cells with segmental apparent mesangiolytic change; fine granular IgM, IgG and C3 deposits were noted by immunofluorescence microscopy; relatively small electron-dense deposits were observed in the widened subendothelial spaces and the mesangium, and loosening of the mesangial matrix varied from place to place electron microscopically. PCR of HPVB19 DNA in the renal biopsy tissue was positive as well as in the peripheral blood. The histological findings suggested that immune-complex-mediated endocapillary proliferative glomerulonephritis is caused by acute HPVB 19 infection. We discuss the differences from poststreptococcal glomerulonephritis and the possible pathogenesis of acute endocapillary proliferative glomerulonephritis associated with HPVB19 infection.     

Rituximab does not compromise the mobilization and engraftment of autologous peripheral blood stem cells in diffuse-large B-cell lymphoma

To investigate effects of the preautografting administration of rituximab on the mobilization and engraftment of peripheral blood stem cells (PBSC), we retrospectively analyzed the outcomes of 43 newly diagnosed diffuse-large B-cell lymphoma patients who received CHOP chemotherapy with or without rituximab as a first-line treatment before autologous PBSC transplantation (PBSCT). There was no difference in the number of CD34(+) cells among PBSC between the non-rituximab and the rituximab groups. Although B-cells were completely depleted from PBSC in the rituximab group, we found no difference in the expression of CXCR-4, VLA-4 and c-Kit on PBSC, indicating that rituximab did not affect the expression of these adhesion molecules, which might be involved in the mechanism of mobilization. There was no significant difference in the recovery of neutrophils and platelets, transplant-related toxicity and post-transplant complications between the two groups. Despite the short follow-up, there was no significant difference in progression-free survival between the two groups. These results indicated no adverse effect of rituximab on the mobilization and engraftment of PBSC. Larger studies are required to determine the impact of rituximab on the mobilization and function of PBSC as well as whether a survival advantage exists in patients who undergo auto-PBSCT with rituximab.     

Clinical and molecular epidemiology of extended-spectrum β-lactamase-producing Escherichia coli and Klebsiella pneumoniae in a long-term study from Japan

The detection rates of extended-spectrum β-lactamase (ESBL)-producing bacteria in Japan are very low (∼5%) compared with those obtained worldwide. Further, the current trend of these bacteria in Japan is not known, and few studies with longitudinal observations have been reported. To obtain epidemiologic data on ESBL-producing bacteria, their genotypic features, and their antibiotic resistance patterns in Japan, we analyzed bacterial isolates from hospitalized patients at our institution over the 7-year period from 2003 to 2009. Of 2,304 isolates, 202 (8.8%) were found to be ESBL producers, including Escherichia coli, Klebsiella pneumonia, and Proteus mirabilis. The detection rates of the ESBL-producing isolates gradually increased and reached 17.1% and 10.5% for the E. coli and K. pneumoniae strains, respectively, in 2009. Genotyping analysis showed that ∼90% of the ESBL-producing isolates carried the CTX-M genotype, in which the CTX-M-9 group was predominant, although the CTX-M-2 group is considered to be the main genotype in Japan; further, many of the strains produced multiple β-lactamases. The detection rates of ESBL-producing bacteria may tend to be high within a limited region in Japan. A countrywide survey is required to understand the trend for ESBL-producing bacteria at the national level. In addition, our findings suggest that the genotypes of the detected ESBL producers are similar to those exhibiting a successful nosocomial spread worldwide.     

Determinants of Bronchodilator Responsiveness in Patients with Controlled Asthma

Short-term bronchodilator responsiveness to an inhaled β 2 adrenergic agonist was assessed by changes in forced expiratory volume in 1 second (FEV₁) in nonsmoking adults with controlled asthma (mild disease, 20 patients; moderate disease, 20 patients; severe disease, 18 patients). Responsiveness correlated significantly with age and with percent of predicted FEV₁ (%FEV₁) except in patients with severe asthma, who showed significantly less responsiveness than others. Thus, responsiveness is closely associated with degree of airflow limitation in patients with controlled asthma and is significantly influenced by severity of disease and by aging.     

Current trends of sentinel lymph node biopsy for breast cancer--a surgeon's perspective.

Sentinel lymph node biopsy (SLNB) is standard care for patients with early-stage breast cancer, and axillary lymph node dissection (ALND) is considered unnecessary when sentinel lymph nodes (SLNs) are tumor-free. Additional non-SLN metastasis in patients with positive SLNs can be estimated using several risk factors such as primary tumor size, metastatic tumor size in SLNs, lymphatic vessel invasion, and so on. All patients with positive SLNs may be treated with further ALND based on their own risk for non-SLN metastasis. Recent randomized clinical trials have already proved less surgical morbidity and better QOL for SLNB alone compared with ALND. However, trials concerning the efficacy of ALND in positive SLNB patients in preventing local regional recurrence and improving overall survival compared with no ALND, and also, concerning the effectiveness of ALND compared with axillary radiation therapy (RT), have not yielded clear results. The prognostic significance of micrometastasis in SLNs or bone marrow also remains to be determined. So far SLNB is not acceptable for patients with positive nodes in the axilla at initial diagnosis even if their axillary metastases are down-staged to negative by neoadjuvant chemotherapy. Although basically SLNB does not need to be performed for patients with pure ductal carcinoma in situ (DCIS), it is recommended for patients with an initial diagnosis of DCIS which is large, palpable, high grade, or found in younger patients. Because these types of DCIS have higher incidences of accompanying invasive lesions. In addition if patients will undergo mastectomy, SLNB is recommended because of the inability to perform SLNB after mastectomy. SLNB may be acceptable for patients with T3 or T4b tumors, even though SLN identification is lower yet SLN involvement is higher compared with T1 or T2 tumors, and systemic adjuvant therapy is more important for patients with T3 or T4b tumors. SLNB is a bridge to further axillary treatment such as ALND or axillary RT, and which strategy, including no further treatment, is best considered individually based on recurrence risk, treatment responsiveness and use or non-use of systemic therapy.     

Comparison of inhibition potentials of drugs against zidovudine glucuronidation in rat hepatocytes and liver microsomes.

Hepatocytes and liver microsomes are considered to be useful for investigating drug metabolism catalyzed mainly via glucuronidation. However, there have been few reports comparing the glucuronidation inhibition potentials of drug in hepatocytes to those in liver microsomes. 3'-Azido-3'-deoxythymidine (AZT, zidovudine) glucuronidation (AZTG) is the major metabolic pathway for AZT. In this study, the inhibition potentials of drugs against UDP-glucuronosyltransferase (UGT)-catalyzed AZTG in the hepatocytes and liver microsomes of rats are compared. The AZTG inhibition potentials of diclofenac, diflunisal, fluconazole, indomethacin, ketoprofen, mefenamic acid, naproxen, niflumic acid, and valproic acid in liver microsomes and hepatocytes were investigated using liquid chromatography with tandem mass spectrometry. Diflunisal (inhibition type: noncompetitive) inhibited AZTG most potently in rat liver microsomes (RLMs) with an IC(50) value of 34 microM. The IC(50) values of diclofenac, fluconazole, indomethacin, ketoprofen, mefenamic acid, naproxen, niflumic acid, and valproic acid against AZTG in RLMs ranged from 34 to 1791 microM. Diclofenac, diflunisal, indomethacin, ketoprofen, naproxen, and valproic acid inhibited AZTG in hepatocytes with IC(50) values of 58, 37, 88, 361, 486, and 281 microM, respectively. These values were similar to those obtained in RLMs. In conclusion, the AZT glucuronidation inhibition potentials of drugs in the hepatocytes and liver microsomes of rats were found to be similar, and liver microsomes can be useful for evaluating UGT isozyme inhibition potentials.     

Tacrolimus administration to a patient with cyclosporine-induced encephalopathy after allogeneic bone marrow transplantation

A 25-year-old woman with severe aplastic anemia received allogeneic bone marrow transplantation from an HLA-identical sibling. Pretransplant conditioning comprised 3.6 Gy of total body irradiation and 200 mg/kg cyclophosphamide. Cyclosporine (CSP) and methotrexate were administered to prevent graft-versus-host disease (GVHD). The patient complained of severe headache soon after CSP administration on day-1. On day 3, convulsion developed and she lost consciousness for 15 min. CT and MRI demonstrated low density areas and high signals, respectively, in the frontal and parietooccipital lobes and splenium of the corpus callosum, suggesting brain edema probably induced by CSP. After immediate withdrawal of CSP, glycerol and prednisolone were instituted, and the patient's condition improved. Thereafter, she developed grade II acute GVHD. This was treated with tacrolimus, which produced no adverse effects including central nervous system (CNS) toxicity. This case illustrates that careful management of CNS disorders induced by CSP can be important in patients undergoing allogeneic bone marrow transplantation.