Infective endocarditis developing as uremia

A 49-year-old man presented with fever and uremic symptoms such as general malaise, leg edema and decreased urine output. He was diagnosed as having infective endocarditis (IE) accompanied by renal failure. Although he had been receiving hemodialysis for a long time, renal function dramatically improved after heart valve replacement. This case suggests that uremia can develop as an initial manifestation of IE and removal of an infected heart valve can improve renal function despite persistent renal failure. From the perspective of recovery of renal function, early surgery should be considered in patients with renal failure following IE.     

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.     

Large Perigraft Seroma After Aortoiliac Bypass with an Expanded Polytetrafluoroethylene Graft: Report of a Case

A 63-year-old man who had undergone aortoiliac bypass with an expanded polytetrafluoroethylene (PTFE) graft was referred to our hospital for investigation and treatment of a possible pseudoaneurysm of the abdominal aorta. A tender, pulsatile, and bulging mass, about the size of an adult fist, was palpated around the navel. Enhanced computed tomography (CT) showed a large low-density area around the abdominal aorta and PTFE graft, and aortography showed a patent graft with no anastomotic leakage. Operative inspection revealed that the pulsatile mass was a large perigraft seroma, and we replaced the PTFE graft with a new woven Dacron graft. The patient has been well with no sign of recurrence for 1 year, although close long-term follow-up is mandatory.     

Concurrent chemo-radiotherapy for nasopharyngeal carcinoma

OBJECTIVE: Because of the low incidence of nasopharyngeal carcinoma (NPC) in Japan, few studies have reported on the use of concurrent chemo-radiotherapy (CCRT) for treatment of this disease. The present study investigated the efficacy and toxicity of CCRT with Carboplatin (CBDCA) and UFT for NPC. PATIENTS AND METHODS: CCRT with injection of CBDCA and oral administration of UFT was given to 21 patients in our institution during 1996-2000. We compared the patients treated with CCRT with those treated with RT alone from 1976 to 1995 or those treated with RT after chemotherapy (Pre-RT chemotherapy) from 1985 to 1995. Overall survival rate (OS), progression free survival rate (PFS) and cause specific survival (CSS) rate were analyzed. RESULTS: The actual 2-year OS, PFS, and CSS of CCRT were 85.7, 66.7 and 90%, respectively. The rates were improved compared to RT alone (37.9, 31.0, and 56.6%) and Pre-RT chemotherapy (58.8, 41.2, and 64.7%). The most frequent and severe acute toxicities were leukopenia (42.9%) and mucositis with grade 3-4 (28.6%), both of which eventually resolved. CONCLUSION: CCRT with CBDCA and UFT is considered to be an effective, convenient, and tolerable treatment, which improves survival rates for NPC patients. Therefore, we recommend this CCRT method for the treatment of NPC.     

Localised vulva Langerhans cell histiocytosis

A cutaneous lesion as sole manifestation of adult Langerhans cell histiocytosis is rare. We report a 65-year old female who presented with vulvar ulcers. Histological examination of the ulcer showed diffuse proliferation of histiocytic cells with large bright cytoplasm that were positively stained for anti-S-100 protein and anti-CD1a antibodies by immunohistochemistry. Electron microscopy demonstrated Birbeck granules in the cytoplasm of the cells. Since there was no other organ involvement, the patient was treated by complete surgical excision without recurrence or other-organ involvement in the 1-year follow-up period.     

Population survey to determine risk factors for Mycobacterium leprae transmission and infection

BACKGROUND: Not every leprosy patient is equally effective in transmitting Mycobacterium leprae. We studied the spatial distribution of infection (using seropositivity as a marker) in the population to identify which disease characteristics of leprosy patients are important in transmission. METHODS: Clinical data and blood samples for anti-M. leprae ELISA were collected during a cross-sectional survey on five Indonesian islands highly endemic for leprosy. A geographic information system (GIS) was used to define contacts of patients. We investigated spatial clustering of patients and seropositive people and used logistic regression to determine risk factors for seropositivity. RESULTS: Of the 3986 people examined for leprosy, 3271 gave blood. Seroprevalence varied between islands (1.7-8.7%) and correlated significantly with leprosy prevalence. Five clusters of patients and two clusters of seropositives were detected. In multivariate analysis, seropositivity significantly differed by leprosy status, age, sex, and island. Serological status of patients appeared to be the best discriminator of contact groups with higher seroprevalence: contacts of seropositive patients had an adjusted odds ratio (aOR) of 1.75 (95% CI 0.922-3.31). This increased seroprevalence was strongest for contact groups living < or =75 m of two seropositive patients (aOR = 3.07; 95% CI 1.74-5.42). CONCLUSIONS: In this highly endemic area for leprosy, not only household contacts of seropositive patients, but also people living in the vicinity of a seropositive patient were more likely to harbour antibodies against M. leprae. Through measuring the serological status of patients and using a broader definition of contacts, higher risk groups can be more specifically identified.     

Fcgamma receptor gene polymorphisms in Japanese patients with systemic lupus erythematosus: contribution of FCGR2B to genetic susceptibility

OBJECTIVE: Human low-affinity Fcgamma receptors (FcgammaR) constitute a clustered gene family located on chromosome 1q23, that consists of FcgammaRIIA, IIB, IIC, IIIA, and IIIB genes. FcgammaRIIB is unique in its ability to transmit inhibitory signals, and recent animal studies demonstrated a role for FcgammaRIIB deficiency in the development of autoimmunity. Genetic variants of FcgammaRIIA, IIIA, and IIIB and their association with systemic lupus erythematosus (SLE) have been extensively studied in various populations, but the results were inconsistent. To examine the possibility that another susceptibility gene of primary significance exists within the FcgammaR region, we screened for polymorphisms of the human FCGR2B gene, and examined whether these polymorphisms are associated with SLE. METHODS: Variation screening of FCGR2B was performed by direct sequencing and polymerase chain reaction (PCR)-single-strand conformation polymorphism methods using complementary DNA samples. Genotyping of the detected polymorphism was done using genomic DNA, with a specific genotyping system based on nested PCR and hybridization probing. Association with SLE was analyzed in 193 Japanese patients with SLE and 303 healthy individuals. In addition, the same groups of patients and controls were genotyped for the previously known polymorphisms of FCGR2A, FCGR3A, and FCGR3B. RESULTS: We detected a single-nucleotide polymorphism in FCGR2B, (c.695T>C), coding for a nonsynonymous substitution, Ile232Thr (I232T), within the transmembrane domain. The frequency of the 232T/T genotype was significantly increased in SLE patients compared with healthy individuals. When the same patients and controls were also genotyped for FCGR2A-131R/H, FCGR3A-176V/F, and FCGR3B-NA1/2 polymorphisms, FCGR3A-176F/F showed significant association. Two-locus analyses suggested that both FCGR2B and FCGR3A may contribute to SLE susceptibility, while the previously reported association of FCGR3B was considered to be secondary and derived from strong linkage disequilibrium with FCGR2B. CONCLUSION: These results demonstrate the association of a new polymorphism of FCGR2B (I232T) with susceptibility to SLE in the Japanese.     

Management of posterior capsule rupture during phacoemulsification using the dry technique

To manage posterior capsule rupture during phacoemulsification, we use a dry technique in which all procedures are performed without an irrigation/aspiration system. The dry technique is characterized by (1) continuous viscoelastic injection instead of fluid irrigation to maintain anterior chamber depth with the posterior capsule and vitreous located posteriorly and (2) static removal of most residual lens material by viscoexpression and/or manual small incision extracapsular cataract extraction without aspiration and dynamic water flow. In 16 cases of posterior capsule rupture managed using the dry technique, the residual nucleus and cortex were readily removed with minimum extension of the ruptured area and new vitreous loss. Although large amounts of viscoelastic material (mean 5.8 mL) were required, rapid and stable visual recovery was comparable to that in patients having uneventful surgery. The dry system is a safe and reliable technique for managing posterior capsule rupture during phacoemulsification.