Brainstem-type Lewy body disease presenting with progressive autonomic failure and lethargy.

The authors report an autopsy case characterized by progressive lethargy and autonomic failure with a distinctive pattern of occurrence of Lewy bodies. Autonomic dysfunction such as sleep apnea, orthostatic hypotension, dysuria, and hypohidrosis predominated with lethargy, whereas parkinsonism was not apparent. Numerous Lewy bodies were widely evident microscopically in brainstem nuclei and the intermediolateral cell columns of the spinal cord, as well as in the sympathetic ganglia, but were rare or absent in the cerebral cortex and other supratentorial structures. Marked neuronal loss was seen in the locus ceruleus, raphe nuclei, dorsal vagal nuclei, and intermediolateral cell columns, but neurons in the substantia nigra, other brain regions, and sympathetic ganglia appeared undiminished. This case represents a specific clinicopathologic form of Lewy body disease occurring predominantly in the brainstem, spinal cord, and sympathetic ganglia.

[A patient with choreoathetosis of the left upper extremity due to acute cerebral infarction].

A 71-year-old woman was admitted to our hospital because of involuntary movement of the left upper extremity. MR image of the brain 15 days after the onset revealed the low intensity in right posterior limb of internal capsule. The lesion was surrounded by thalamus, subthalamic nucleus, and globus pallidus with enhancement by Gd-DTPA. Surface EMG revealed irregular grouped discharge in short duration and grouped discharge in long duration in the left upper extremity. Those features are compatible with one of choreoathetosis. Choreoathetosis due to cerebral infarction in acute phase is rare. We discussed pathophysiology of this involuntary movement due to lacunar infarction of posterior limb of internal capsule in acute phase.

Induction of MHC class II antigen expression on murine microglia by interleukin-3.

The effects of various cytokines on MHC class II antigen expression were examined in murine microglia. Interleukin-3 (IL-3), as well as interferon-gamma (IFN-gamma), induced MHC class II antigen expression on these cells. IL-3 additionally enhanced MHC class II antigen expression induced by IFN-gamma. The induction of MHC class II antigen expression by IL-3 was not mediated via IFN-gamma production, because the effect was not blocked by antibodies to IFN-gamma. In contrast, granulocyte-macrophage colony-stimulating factor (GM-CSF) did not affect the expression of MHC class II antigen on naive cells and down-regulated IFN-gamma-mediated induction of MHC class II antigen expression on microglia. Because IL-3 and GM-CSF are apparently produced in the central nervous system, MHC class II antigen expression on microglia may be regulated by these cytokines synthesized in the central nervous system.

[An autopsied case of type II citrullinemia--transient effectiveness with either citrate or benzoate to the consciousness disturbance].

A 44-year-old man suffered from repeated impairment of consciousness associated with flapping tremor, myoclonus and generalized convulsions, and died in coma 6 months after admission. He had had a psychosomatically underdeveloped childhood, with a propensity for legumes without a family history of the same or a record of consanguinity. On admission, he had disturbed consciousness and emaciation without other physical abnormalities. The EEG revealed diffuse slow waves with occasional appearance of triphasic waves. A high level of serum citrulline (534.7 nmol/ml) was recognized and the assay of urea cycle enzymes in the liver demonstrated decreased argininosuccinate synthetase (ASS) activity (0.062 U/g liver, 7.4% of that in normal liver), although no kinetic abnormality was found. Accordingly he was diagnosed as having type II citrullinemia. In addition, this case could be classified as cluster type of localization of the ASS in the liver by immunohistochemical study. There were characteristic findings concerning his clinical picture and laboratory data, such as a significant correlation between the grade of disturbed consciousness and arterial blood gas pH (r = 0.61, p less than 0.01). However, the blood ammonia level did not always correlate with the severity of disturbed consciousness. Oral treatment with sodium citrate and sodium benzoate was very effective, though transiently, for disturbed consciousness in this case. Pathological findings of the autopsied liver were fatty change and fibrosis. Neuropathologically, characteristic findings were brain edema with cerebellar tonsilar herniation, laminar necrosis with spongy formation in cerebral cortex, and Alzheimer type II glia. The relationship between citrullinemia and other hepatic encephalopathy was also discussed.

Superior sagittal sinus thrombosis associated with androgen therapy for hypoplastic anemia.

Of 27 patients with hypoplastic anemia treated between 1971 and 1974 with male hormone and protein-assimilating hormone, 3 developed superior sagittal sinus thrombosis (SSST). The clinical symptoms and signs and angiographic findings of SST were characteristic enough to allow an early diagnosis. Signs related to SST were seizures, hemiplegia, facial palsy, stupor, and coma, with the most important prodrome and consistent subjective complaint being headache. Following discontinuation of the hormone therapy, neurological signs and symptoms related to SSST gradually subsided. In all cases, the hematological picture improved with discontinuation of the hormone therapies. It appears that administration of male hormone can be associated with the development of SSST. If neurological symptoms and signs of SSST appear, administration of the hormones should be discontinued.

The nocturnal intragastric pH in EEG sleep stages in peptic ulcer patients.

In 10 peptic ulcer patients, 5 duodenal ulcer and 5 gastric ulcer patients, the relation of nocturnal intragastric pH to EEG sleep stages was examined. The nocturnal intragastric pH was monitored by pH-measuring telemeter and sleep stages were recorded simultaneously by electroencephalography throughout the night. The EEG sleep stages were classified after the criteria of Dement and Kleitman. The average of intragastric pH level at each sleep stage was higher in gastric ulcer than the duodenal ulcer. The intragastric pH level became low as the patients' sleep advanced to deep stage. This tendency was more likely in duodenal ulcer patients than the gastric ulcer patients, which indicated that the cephalic phase might play an important role in the pathogenesis of hyperacidity in duodenal ulcer.