Cerebral germinoma with marked granulomatous inflammation: Granulomatous germinoma

Cerebral germinomas with granulomatous inflammation are rare lesions that can present diagnostic difficulties. Four cases (two male and two female) of germinomas with pronounced inflammatory reaction are presented. The age ranged from 14 to 21 years (mean 18). Three patients with vision defects had masses around the sellar region, and a long duration of symptoms (2, 4 and 5 years). The fourth patient had a mass in the temporal lobe; she had convulsions and the duration of her symptoms was short (3 weeks). All lesions consisted of inflammatory changes with scattered neoplastic germinoma cells that expressed placental alkaline phosphatase. The inflammation area occupied more than two-thirds of the mass, and consisted of macrophages and their syncytial forms of mutinucleated giant cells, T-cells, B-cells, plasma cells, fibroblasts, and histiocytes or glial cells. Sarcoid granulomata were frequently seen, and multinucleated giant cells with Schaumann's bodies were also visible. The term ‘cerebral granulomatous germinoma’ is proposed for these unusual tumors. Moreover, it is likely that the study of cerebral granulomatous germinoma may provide some important clues towards the understanding of granulomatous inflammation in organs in general.     

Unusual postoperative hemorrhage in a patient with ruptured aneurysm and hemophilia B

A case of ruptured cerebral aneurysm with hemophilia B is reported, and discussion is made concerning the management of mild type hemophilia in surgical operations. A 41-year-old male came to our hospital with complaints of severe headache, vomiting, and transient consciousness disturbance. His dentist said the patient had a mild bleeding tendency when he was 30 years old, however no postoperative hemorrhage was repeated in appendectomy in his childhood. He also had had no episodes of spontaneous bleeding. CT scan on admission showed subarachnoid hemorrhage, and angiography revealed a ruptured aneurysm at the trifurcation of the left middle cerebral artery. His coagulation screening tests (bleeding time, clotting time, prothrombin time, and activated partial thromboplastin time) were normal. An aneurysmal neck clipping was carried out, and operators did not detect any bleeding tendency during the surgery. CT scan on the next day showed no remarkable finding. On the third postoperative day, right hemiparesis occurred. Left putaminal hemorrhage took place. His coagulation tests and FDP were also normal. The hematoma was partially evacuated. After the second operation his condition was good, and rehabilitation program started. On the 15th hospital day his consciousness deteriorated suddenly, and CT scan showed a massive epidural hematoma on the left. His prothrombin time elongated mildly, but other tests were normal. Coagulation factors VIII and IX were examined and the factor IX was 22.5% of control. He was thought to be a patient with mild type hemophilia B. Despite a third operation for hematoma removal he died on the 20th hospital day. Mild type hemophilia B does not bleed spontaneously.(ABSTRACT TRUNCATED AT 250 WORDS)     

A case of spinal epidural abscess in a renal transplant recipient

A 44-year-old male underwent a cadaveric renal transplantation at the university hospital of Tsukuba on March 3, 1979. On June 11, 1979, he was discharged this hospital. Immunosuppressive therapy with azathioprine and methylprednisolone was done. On November 1, 1979, he developed back pain associated with fever. On November 3, 1979, he was admitted to the university hospital of Tsukuba. Laboratory study revealed leucocytosis. CRP inserum was positive. But pneumonia, urinary tract infection and infectious skin lesion were ruled out by physical, radiological and laboratory examination. On November 16, 1979, he became paraparetic. On the next day, he consulted the neurosurgical unit. Neurological findings were as follows: paraplegia, and hypesthesia and hypalgesia below the level of T4, and bilateral hyperrefrexia of P.T.R. and A.T.R. Lumbar myelogram revealed a complete block at the level T7. On November 17, 1979, a laminectomy from T4 through T7 was performed. The epidural abscess containing yellow pus was found and totally removed. Gram-positive rods were isolated on bacteriologic culture. On the 7th postoperative day, the sensory level dropped to L4 bilaterally and the muscle strength in the lower extremity became fair. About 3 years after operation, he became to be able to walk without cane. Discussion was made about this case together with previously reported cases.     

Heterogeneity of presynaptic muscarinic receptors located on different tissue preparations

Three different tissue preparations were used to demonstrate the heterogeneity of presynaptic muscarinic receptors that modulate neurotransmitter release. The presynaptic antimuscarinic potency of several muscarinic antagonists was characterized with the enhancement of the neurotransmitter release evoked by electrical stimulation on the guinea-pig ileum Auerbach plexus, the guinea-pig atrium and the rat brain cortex. Presynaptic muscarinic receptors located on the Auerbach plexus proved to be different of those present on the cortical cholinergic interneurons and on the sympathetic plexus of the guinea-pig atrium.     

OKT3 salvage therapy in a quadruple immunosuppressive protocol in cadaveric renal transplantation

Since the introduction of OKT3 at our center in January 1986, we have performed 246 cadaveric renal transplants (220 primary, 26 nonprimary). All patients received quadruple immunosuppression consisting of prednisone, azathioprine, and the sequential use of Minnesota antilymphoblast globulin (MALG) and cyclosporine. OKT3 (Orthoclone OKT3) therapy was reserved for corticosteroid- and/or ALG-resistant rejection. Of the 246 patients, 138 developed one or more rejection episodes (56.1%). Ninety-seven (70.3%) were successfully reversed with prednisone and/or ALG, whereas 41 (29.7%) required additional treatment with OKT3. Initial graft salvage occurred in 34 (82.9%) patients treated with OKT3, but rejection recurred in 18 (52.9%) and was successfully reversed in only 6 patients. However, the rate of recurrent rejection was much lower in patients given OKT3 early (14%), shortly after it was apparent that high-dose corticosteroid therapy was proving ineffective, than in patients who received OKT3 after a prolonged or second course of corticosteroids (64%) or ALG (60%). Graft survival after a mean follow-up interval of 11 months in all OKT3-treated patients was 54%. One or more infections occurred in 19 (46%) patients treated with OKT3. Patients developing infections following OKT3 therapy received significantly larger total doses of prednisone during graft rejection (46.3 mg/kg vs. 27.9 mg/kg, P less than .05) than OKT3-treated patients who did not develop infectious complications. Our experience shows that use of OKT3 for treatment of corticosteroid- and/or ALG-resistant rejection is associated with a high rate of recurrent rejection, except when given early, as soon as it is clear that high-dose corticosteroid therapy is not reversing the rejection episode. It further suggests that prolonged administration of high-dose corticosteroids and possibly ALG for the treatment of rejection prior to beginning OKT3 greatly increases the rate of infection following OKT3 therapy.