Identification and viability assessment of dermatophytes infecting nail based on quantitative PCR of dermatophyte actin (ACT) mRNA]

The diagnosis and choice of treatment for dermatophytoses are usually based on the result of microscopic observation of hyphal elements and culture. However, false negative cultures have sometimes been encountered and appropriate timing of discontinuation of treatment has not been formulated. In this study, we attempted the identification and viability assessment of dermatophytes based on the quantitative measurement of dermatophyte actin (ACT) mRNA. An internal fragment of the ACT, 725 to 762 bp, was isolated by PCR from the genomic DNA of dermatophytes and sequenced. ACT intron-based primers were dermatophyte species-specific and primer pairs crossing the intron were dermatophyte genus-specific. The LightCycler (LC) instrument, employing the two-step RT-PCR/fluorescent hybridization system, was used to quantify the actin mRNA (ACT) of dermatophytes. A 669 bp ACT cDNA fragment was used as a quantification standard. Several mg of samples were collected from skin scales or nail plates before and after the treatment using oral terbinafine. The results indicated that quantification of ACT mRNA correlated with the results of culture and KOH examination and that copy numbers of dermatophyte ACT mRNA per mg sample decreased with progression of the therapy. This method comprises a sensitive (1 fg), specific, rapid (< 4 h) and quantitative assessment of the viability and identification of dermatophytes in skin tissue.     

Coexistence of cerebral aneurysm and angiographically occult AVM in the occipital lobe; a case report]

The authors report a case of an 8-year-old boy with coexistent aneurysm and arteriovenous malformation (AVM) at the periphery of the left middle cerebral artery. The patient was referred to our hospital because of intracerebral hematoma in the occipital lobe. Angiography revealed an aneurysm at the periphery of the left middle cerebral artery. A small AVM was found, adjacent to the aneurysm, by histological examination of the aneurysm and surrounding tissue resected by surgery. The patient was discharged uneventfully 17 days after surgery. The association of intracranial aneurysm with AVM is reported to be seen in 1.4% of patients with intracranial aneurysms, and 6.4% to 16.7% of patients with an intracranial AVM. Three hypotheses have been proposed in order to explain the association of an aneurysm with AVM: (1) Congenital multiple disorders of vascular development, (2) Hemodynamic stress resulting from the presence of an AVM, (3) Coincidence without any causal relationship between them. The coexistence of the two vascular lesions, adjacent to each other at the peripheral cerebral arteries is rare. Only 7 cases have been reported in the literature. Four of the 8 cases including ours were children, and 6 of the 8 cases were thought to have had a hemorrhage from the AVM. It is likely that the coexistence of the two lesions in our patient is of congenital origin, because the influence of hemodynamic stress from the AVM seemed little and coexistence of the lesions as found in our case is more frequently seen in childhood.     

Lymphatic drainage of the gallbladder

Based upon detailed dissections of the lymphatic system in adult cadavers, the lymphatic drainage of the gallbladder was divided into three pathways: (1) The cholecystoretropancreatic pathway, which had two routes, one running spirally from the anterior surface of the common bile duct to the right rear, and the other running almost straight down from the posterior surface of the common bile duct. These routes converged at the principal retroportal node at the posterior surface of the head of the pancreas. (2) The cholecysto-celiac pathway; this was the route running to the left through the hepatoduodenal ligament to reach the celiac nodes. (3) The cholecysto-mesenteric pathway; this was the route running to the left in front of the portal vein to connect with the nodes at the superior mesenteric root. The cholecysto-retropancreatic pathway can be regarded as the main pathway, and the principal retroportal node appeared to be critical as the main terminal node in the visceral lymphatic system of the gallbladder. These three pathways converged with the abdomino-aortic lymph nodes near the left renal vein, and the nodes in the interaortico-caval space were considered to be of particular importance. Offprint requests to: M. Ito     

A case of mixed connective tissue disease successfully treated for hemophagocytic syndrome with intermittent intravenous injection of cyclophosphamide]

A 52 year-old woman noticed general fatigue, polyarthralgia, and muscle weakness of lower extremities in October 2001. In December, she felt difficulty in walking due to muscle weakness. In January 2002, she admitted another hospital because of dyspnea on exertion and edema of lower extremities. Laboratory test revealed leukocytopenia, the elevation of creatine kinase and positive anti-U1-RNP antibodies. Her chest computed tomography (CT) showed severe interstitial pneumonia. Cardiac echogram revealed that she had pericardial effusion and pulmonary hypertension. Then she was transferred to Keio University Hospital and she was diagnosed as having mixed connective tissue disease (MCTD) manifestating myositis, interstitial pneumonia, pulmonary hypertension and pericarditis. Prednisolone (PSL) 60mg daily following to methylprednisolone (mPSL) pulse therapy was begun and her symptoms were gradually improved. In middle of February, she complained of high fever over 39.0 degrees C. Bacterial culture tests were negative and laboratory data indicated pancytopenia and a high level of serum ferritin. Bone marrow aspiration revealed hemophagocytosis in bone marrow specimens and she was diagnosed as having hemophagocytic syndrome associated with MCTD. mPSL pulse therapy was not effective and intermittent cyclophosphamide pulse therapy (IV-CY) was performed resulting in improvement of the symptoms. This case suggested the effectiveness of IV-CY therapy in patients with corticosteroid-resistant HPS associated with connective tissue diseases.     

Angiotensin I-converting enzyme inhibitor improves reactive hyperemia in elderly hypertensives with arteriosclerosis obliterans.

Endothelial function in elderly hypertensive patients with arteriosclerosis obliterans has not been evaluated. We examined whether antihypertensive drugs improve vasodilatory response to reactive hyperemia of the limbs in elderly hypertensive patients (83 +/- 8 [SD] years) without (n=46, 0.9 < or = ankle-brachial pressure index < or = 1.4) and with (n=24) arteriosclerosis obliterans (ankle-brachial pressure index < 0.2). Patients were randomized for treatment with monotherapy of either temocapril (14 with and 26 without arteriosclerosis obliterans) or amlodipine (10 with and 20 without arteriosclerosis obliterans) for 6 months. Blood flows of the forearms and legs were measured by strain-gauge plethysmography. The vasodilatory response to the release of compression of the forearms and thighs at 200 mmHg or 20 mmHg more than systolic blood pressure for 5 min and to sublingual administration of nitroglycerin (0.3 mg) was assessed. The maximum reactive hyperemic flow in 35 legs with arteriosclerosis obliterans was significantly (p < 0.001) decreased compared to the value in legs in the control hypertensive subjects. Moreover, maximum reactive hyperemic flow in the forearms of patients with arteriosclerosis obliterans was significantly (p = 0.002) decreased compared to that in the control subjects. Blood pressure was similarly decreased by treatment with temocapril or amlodipine. Response to nitroglycerin (0.3 mg) was not changed by either drug. Treatment with temocapril significantly improved maximum reactive hyperemic flow of not only the legs and forearms in control hypertensives but also the legs and forearms in patients with arteriosclerosis obliterans, and attenuated the worsening of activity of daily living in these patients, although treatment with amlodipine did not. These results suggest that the angiotensin-converting enzyme inhibitor temocapril has a beneficial effect on endothelial function in elderly patients with arteriosclerosis obliterans.     

EFFECTIVENESS OF CYTODIAGNOSIS WITH PANCREATIC DUCT LAVAGE FLUID FOR PANCREATIC DUCTAL CARCINOMA: NEW SAMPLING TECHNIQUE

Background: Pancreatic carcinoma is one of the most lethal cancers. Because pancreatic carcinoma is still very difficult to diagnose in its early stage, many of these patients will be considered unsuitable for surgery. If a cytological diagnosis is obtained at initial endoscopic retrograde cholangiopancreatography (ERCP), suitable treatment will be initiated without delay. Methods: To increase the number of exfoliated cells from the pancreatic duct, we devised a new technique, pancreatic duct lavage fluid (PDLF), following bronchoalveolar lavage fluid. The present paper reports the effectiveness of cytological examination using PDLF in the diagnosis of pancreatic carcinoma. We examined 18 pancreatic carcinoma cases. After the endoscopic retrograde pancreatography (ERP), PDLF was collected from a double‐lumen catheter inserted into the main pancreatic duct. Saline injected from the lumen for the injection, and PDLF was aspirated from the other lumen for the guidewire at the same time. The cytological examination was performed using PDLF. Results: Exfoliated cells were more frequently found in PDLF from all patients. In 15 cases (83%), cytological examination of PDLF revealed positive cytological results as the diagnosis of pancreatic carcinoma. Conclusion: Cytological examination using PDLF has a high sensitivity for detection of pancreatic carcinoma. The new examination, PDLF, is simple, safe and effective, so we expect PDLF to become widely popular.     

Study of the duration of antimicrobial chemotherapy in mycoplasmal pneumonia]

We assessed the period of administration of antibiotics required for cases of mycoplasmal pneumonia. The subjects were 38 patients with mycoplasmal pneumonia admitted to our hospital. These patients were treated with 100 mg minocycline or 500 mg erythromycin by intravenous infusion twice a day. They were divided into a 6 day-administration group (Group A; 16 cases) and a 9 day-administration group (Group B; 17 cases). Administration was discontinued on the 4th day or earlier in 5 cases due to side effects. A comparative assessment was made between Groups A and B with respect to body temperature, WBC, erythrocyte sedimentation rate, CRP, and chest X-ray on the 3rd, 6th, and 9th days of treatment, but no significant difference was observed. Residual shadows at the end of treatment were present in 100% of Group A and in 47% of Group B, but they disappeared gradually in both groups. No cases of recurrence were observed in either Group A or B within 1 month after the completion of treatment. Regarding the treatment period for mycoplasmal pneumonia by intravenous infusion of minocycline or erythromycin, no significant clinical difference was observed between the 6 day-administration group and the 9 day-administration group, suggesting that 6 days of administration is sufficient for treatment.     

Surgical Treatment of Intractable Seizures Due to Hypothalamic Hamartoma

Summary: A 6.5-year-old boy developed seizures at age 2.8 years consisting of episodes of unconsciousness and laughing attacks. By age 6 years, multiple seizure types, including generalized tonic-clonic (GTC), complex partial (CPS) and akinetic seizures, and drop attacks were occurring several times daily. EEG showed multifocal epileptic discharges. Antiepileptic drugs (AEDs) did not control the seizures. With progression of the epilepsy, cognitive deterioration developed. There were no manifestations of precocious puberty. Neuroimaging disclosed a suprasellar mass in continuity with the hypothalamus, and a diagnosis of hypothalamic hamartoma was made. After surgical resection of the hamartoma, the seizures were completely alleviated, and the epileptic EEG discharges disappeared. Improvement of mental function was also noted.     

Glial localization of four‐repeat tau in atypical progressive supranuclear palsy

In the present case, a patient in whom limb apraxia and asymmetrical parkinsonism developed suggesting corticobasal degeneration, is reported. Neuropathologic examination revealed numerous tufted astrocytes in the precentral cortex in addition to the characteristic pathologic findings of PSP. Therefore, on the basis of clinicopathologic features, atypical progressive supranuclear palsy was diagnosed. In addition, the brain tissue of the present patient was investigated with an antibody specific for four‐repeat tau (4R‐tau). In the precentral cortex, numerous tau‐positive tufted astrocytes, pretangles, and threads were positive for 4R‐tau. Using a confocal microscopy we demonstrated that tufted astrocytes positive for 4R‐tau were adjacent to astrocytes positive for GFAP. The present findings suggest that accumulation of four‐repeat tau in astrocytes is a degenerative process rather than a reactive process.