Acute encephalopathy associated with influenza and other viral infections

Acute encephalopathy is the most serious complication of pediatric viral infections, such as influenza and exanthem subitum. It occurs worldwide, but is most prevalent in East Asia, and every year several hundreds of Japanese children are affected by influenza-associated encephalopathy. Mortality has recently declined, but is still high. Many survivors are left with motor and intellectual disabilities, and some with epilepsy. This article reviews various syndromes of acute encephalopathy by classifying them into three major categories. The first group caused by metabolic derangement consists of various inherited metabolic disorders and the classical Reye syndrome. Salicylate is a risk factor of the latter condition. The second group, characterized by a systemic cytokine storm and vasogenic brain edema, includes Reye-like syndrome, hemorrhagic shock and encephalopathy syndrome, and acute necrotizing encephalopathy. Non-steroidal anti-inflammatory drugs, such as diclofenac sodium and mephenamic acid, may aggravate these syndromes. Severe cases are complicated by multiple organ failure and disseminated intravascular coagulation. Mortality is high, although methylprednisolone pulse therapy may be beneficial in some cases. The third group, characterized by localized edema of the cerebral cortex, has recently been termed acute encephalopathy with febrile convulsive status epilepticus, and includes hemiconvulsion-hemiplegia syndrome and acute infantile encephalopathy predominantly affecting the frontal lobes. Theophylline is a risk factor of these syndromes. The pathogenesis is yet to be clarified, but an increasing body of evidence points to excitotoxicity and delayed neuronal death.     

Reoperation for a patient with starr-edwards aortic valve malfunction due to pannus formation twenty-nine years after implantation

We report a re-do case of severe aortic valve stenosis due to pannus formation 29 years after an aortic Starr-Edwards caged-ball valve implantation. A huge shelf of calcified and thick pannus tissue below the valve had reduced the already small orifice by at least a third in surface area. The explanted Starr-Edwards valve revealed no mechanical or structural failure. Early detection and treatment of pannus outgrowth is essential in order to prevent life-threatening prosthetic valve malfunctions.     

Microheterogeneity of regional myocardial blood flows in low-perfused rat hearts evaluated by double-tracer digital radiography.

Using (3)H- and (125)I-labeled desmethylimipramine (DMI) for regional flow tracers, we established a two-time measurement method for the spatial pattern of myocardial perfusion in cross-circulated rat hearts. Myocardial extractions and retentions of these tracers were confirmed to be satisfactory; however, the latter were less than 90% after 3 min at a perfusion rate of 2.9 ml/min/g, limiting the present application to a short-time perfusion measurement. Distributions of myocardial depositions were separated by subtraction digital radiography with 400-microm pixel resolution. Its feasibility was examined by regression analysis between local deposition densities of (3)H- and (125)I-DMI injected simultaneously. The slope, y-intercept, and correlation coefficient (r) of the regression line were 0.98+/-0.04, 0.02+/-0.04, and 0.95+/-0.03, respectively, indicating the validity of the present image subtraction technique. The spatial pattern of myocardial perfusion in response to flow reduction was evaluated by the injections of (3)H- and (125)I-DMI, respectively, before and after a nearly 70% flow reduction. A significant correlation between normalized density distributions of these tracers was found in both subepicardium (r=0.77+/-0.12) and subendocardium (r=0.73+/-0.20), indicating the stable pattern of myocardial perfusion. However, the coefficient of variation of tracer densities showed a decrease of subendocardial flow heterogeneity from 35+/-15% to 31+/-16%. Thus, flow differences between originally high- and low-flow regions in subendocardium were reduced on a relative basis during low perfusion.     

SUCCESSFUL ENDOSCOPIC CLOSURES OF COLONIC PERFORATIONS REQUIRING ABDOMINAL DECOMPRESSION AFTER ENDOSCOPIC MUCOSAL RESECTION AND ENDOSCOPIC SUBMUCOSAL DISSECTION FOR EARLY COLON CANCER

Endoscopic submucosal dissection (ESD) for colorectal cancer is not widely accepted because of its technical difficulty and the risk of perforation. In addition, the risk of peritonitis cannot be completely eliminated even if a perforation is closed successfully. Reported here are two cases of early colon cancer in which the patients sustained iatrogenic perforations of the ascending colon during conventional endoscopic mucosal resection and of the sigmoid colon during ESD, respectively, requiring abdominal decompression with an 18 G Medicut needle. Both of these perforations were successfully treated by endoscopic clipping. In conclusion, conservative medical management may be possible in patients who have undergone successful closure of colonic perforations using endoscopic clipping. In order to perform immediate endoscopic closure, abdominal decompression has been useful to decrease patient discomfort and colonic lumen collapse. Now, CO₂ insufflation is being used effectively for the prevention of pneumoperitoneum.     

A CASE OF EARLY GASTRIC CANCER ACCOMPANIED BY DIEULAFOY ULCER IN A YOUNG WOMAN

A case of early gastric carcinoma accompanied by Dieulafoy ulcer is presented. The patient, a 26‐year‐old female, visited our emergency room with chief complaints of massive hematemesis and tarry stool. The initial endoscopic examination revealed a superficial depressed lesion with a faded color accompanied by a tiny ulcer with converging folds at the anterior wall of the middle gastric body. Although no active bleeding vessel was found at that time, the patient was admitted to our hospital for further check‐ups and treatment. On the 6th hospital day, she developed massive hematemesis resulting in shock. Urgent endoscopy, this time, disclosed an exposed bleeding vessel at the small ulcer floor previously mentioned, and endoscopic hemostasis was achieved. Since, however, a biopsy at initial examination from the surrounding depressed area proved carcinoma, a partial distal gastrectomy was subsequently carried out. Histological examination of the resected specimen confirmed the diagnosis of carcinoma limited to the mucosa and submucosa along with findings consistent with Dieulafoy ulcer. This is a rare case of combination of early cancer and Dieulafoy ulcer particularly in such a young patient. A review of the literature is also presented.     

Case of X-linked lymphoproliferative syndrome (XLP) with multiple nodular lesions in the brain]

We reported a case of X-linked lymphoproliferative syndrome (XLP) with multiple nodular lesions in the brain and lungs. A 21-year-old man was admitted because of one month history of low grade fever, headache, nausea, and amnesia. He developed agammaglobulinemia following Epstein-Barr virus infection at 3-year-old, and thereafter was administered 7.5g of immunoglobulin every 3 weeks with a diagnosis of XLP. Physical examination was unremarkable on admission. Neurological examination revealed disorientation of time, and bilateral gaze-evoked nystagmus. Neuropsychological tests demonstrated impairment of recent memory and calculation. Pleocytosis (83/microl) and increase of protein (1269 mg/dl) and IgG (141 mg/dl) in the CSF were observed. Brain MRI showed multiple nodular lesions with high intense signal on T2-weighted images and Gd-DTPA enhancement on T1-weighted images. Chest CT showed multiple nodular lesions in the bilateral lungs. The needle lung biopsy was performed, which showed infiltration of lymphocytes around the vessels. An immunohistochemical study showed that the infiltrating cells were mainly CD8 positive T lymphocytes. B lymphocyte and plasma cells were not seen. The histological findings excluded intravascular malignant lymphoma and lymphomatoid granulomatosis. Therefore we diagnosed lymphoid vasculitis. The patient developed pancytopenia caused by hemophagocytic syndrome 48 days after admission and was treated with 1 g of methylprednisolone per day for 3 days and a tapered dose of steroid (500 mg to 125 mg of methylprednisolone and 60 mg to 10mg of predonisolone) for 21 days, which resulted in the improvement of clinical features (hemophagocytic syndrome and central nervous system symptoms) and the abnormal CSF findings. The multple nodular lesions in the brain and the lungs shrank 1 month after treatment and disappeared 11 months later. There are few reports concerning lymphoid vasculitis with XLP, and no effective treatment has been described. Our case suggests that steroid therapy may be useful for the treatment of lymphoid vasculitis in XLP.     

Comparison of Tympanic, Esophageal and Blood Temperatures during Mild Hypothermic Cardiopulmonary Bypass: A Study using an Infrared Emission Detection Tympanic Thermometer

Objective. Tympanic temperature can be obtained instantaneously using an infrared emission detection (IRED) thermometer. Its accuracy has been documented in a variety of clinical settings, but its performance at low body temperatures is still unknown. In this study we evaluated its performance during coronary artery revascularization surgery in which mild hypothermic cardiopulmonary bypass (CPB) was used. Methods. Thirty adult patients undergoing coronary artery bypass graft surgery were enrolled in the study. Tympanic temperature obtained using IRED thermometry (Tt1) was compared with core temperatures from the esophagus (Te), and venous blood of CPB (Tv) before, during, and after CPB. We also measured tympanic temperature using a thermocouple probe (Tt2) in 16 of the 30 patients in order to study the agreement between the two methods. Values for correlation coefficients and limits of agreement were computed to assess the degree of agreement among the temperatures obtained. Results. The highest agreement with Tv during CPB was obtained from Tt1 (r = 0.94, 0.41 ± 1.73, limits of agreement) and from Te (0.91, 0.36 ± 2.46). Tt1 also showed good agreement with Tt2 during surgery. Conclusions. Infrared tympanic thermometry is a reliable, alternative method to measure tympanic temperature and may be useful to assess core temperature in both normothermic and mild hypothermic conditions.