Repeated Syncope Following COVID-19 Infection.

A 74-year-old woman presented to our hospital with syncope after a coronavirus disease 2019 (COVID-19) infection. Upon admission, she passed out, and an 8 second sinus arrest was detected during telemetry monitoring. During the next syncope episode, telemetry monitoring showed that her heart rate decreased from 80 to 36 bpm, accompanied by a 2.4 second pause. A permanent pacemaker was implanted; however, the patient still experienced syncope. The head-up tilt test revealed a vasodepressor reflex syncope. The need for permanent pacemakers in patients with syncope following COVID-19 therefore remains controversial.

Clinical Characteristics of the Patient With Unmeasurable Ankle-Brachial Index in Endovascular Treatment.

Introduction Ankle-brachial index (ABI) is an important indicator to diagnose lower extremity arterial disease (LEAD). However, patients with unmeasurable ABI are sometimes excluded from the analysis and their clinical characteristics are poorly understood. Methods One hundred twenty-two consecutive Japanese subjects (mean age, 72 years), who underwent successful endovascular treatment (EVT) for lower extremity arteries at our hospital were retrospectively studied. Results Of the 122 patients, 23 (19%) patients presented an unmeasurable ABI before EVT. Five of 23 (22%) had still an unmeasurable ABI one day after EVT. Comorbidities including hypertension, diabetes, dyslipidemia, hemodialysis, smoking, ischemic heart disease, atrial fibrillation, and past-EVT history were not different between ABI measurable and unmeasurable patients. However, patients with unmeasurable ABI presented a significantly higher degree of Rutherford category and a smaller number of tibial vessel runoff than patients with measurable ABI before EVT (p<0.05 and p<0.01, respectively). There was no difference in the lesion site between the two groups. The event rate including all-cause mortality, re-EVT, lower limb amputation, and bypass surgery did not differ between two groups four years after EVT. ABI after four years of initial EVT did not differ between pre-EVT measurable and unmeasurable patients (0.96 vs. 0.84, p=0.48). Conclusions Patients with unmeasurable ABI before EVT were characterized by higher degree of Rutherford categorization and a small number of tibial vessel runoff, but there was no significant difference in outcomes during the follow-up period.

Subcutaneous-implantable cardioverter defibrillator lead dislodgement in a juvenile catecholamine-induced polymorphic ventricular tachycardia patient.

Catecholaminergic polymorphic ventricular tachycardia (CPVT) is a relatively rare inherited arrhythmic disease that causes sudden cardiac death, and is caused by mutations in the cardiac ryanodine receptor (RyR2) or sarcoplasmic reticulum protein calsequestrin 2 gene (CASQ2). A 16-year-old man was diagnosed with CPVT and was implanted with a Subcutaneous-implantable Cardioverter Defibrillator (S-ICD), but defibrillation electrode detachment occurred early after placement. We suspected that a two-incision technique was the possible cause. We also report on changes in surface ECG in remote monitoring of the device. TAKE HOME MESSAGE  Although two-incision techniques are becoming the mainstream method of S-ICD implantation, we should consider that the three-incision technique may be advantageous in highly active patients. Remote monitoring may also be useful for early detection of S-ICD dislodgement.

Multiple hepatocellular carcinomas developed 15 months after commencement of chemotherapy for elderly acute myelogenous leukemia.

In May 2006, a 72-year-old man with acute myelogenous leukemia (M4Eo) was admitted to our hospital. He had been receiving antiandrogen treatment for prostate cancer (after an operation in 1998) and treatment for diabetes mellitus. He received chemotherapy according to the JALSG GML200 protocol, which led to complete remission; however, in January 2007, his leukemia recurred. CAG combination chemotherapy also resulted in complete remission by May 2007. In August 2007, he developed multiple liver tumors, abdominal pain, and fever. Contrast-enhanced computed tomography revealed hypovascular tumors in both early and delayed phases. Angiography showed ring-like tumor staining and a massive tumor, similar to those seen in metastatic hepatocellular carcinomas (HCCs). He eventually died because of aggressive enlargement of liver tumors during the following month accompanied by the simultaneous recurrence of leukemia and unsuccessful embolization of the hepatic artery. Autopsy specimens showed fibrosis and considerable iron deposition in the liver, suggested secondary hemochromatosis due to transfusion. We also detected multiple moderately differentiated primary HCCs. Secondary hemochromatosis, androgen imbalance, and humoral factors from leukemic cells were believed to be the causes of the rapid onset and development of HCCs.

[A case of peritonitis carcinomatosa from goblet cell carcinoid of the appendix treated by intraperitoneal paclitaxel and systemic S-1 chemotherapy].

Goblet cell carcinoid of the appendix is a rare neoplasm and clinically tends to take a malignant course. Most cases are young and early stage, and the surgical strategy is available. But appropriate chemotherapy for inoperable cases with peritoneal dissemination is not established. A 77-year-old woman with a past history of appendectomy was admitted to our hospital complaining of abdominal fullness. Abdominal computed tomography showed massive ascites and slight contrast enhancement of appendix. A tumor was found by colonoscopic examination at the orifice of vermiform and was diagnosed pathologically as goblet cell carcinoid of the appendix. Laparoscopy showed multiple peritoneal dissemination. We performed intraperitoneal paclitaxel(PTX)administration at 70 mg/m(2) week without any resection of the tumor. Ascites were reduced immediately, but drug-induced interstitial pneumonia occurred due to PTX. After steroid therapy, we switched to systemic S-1 therapy. For about one year, her tumor was controlled but became worse thirteen months after diagnosis and died. It is thought that intraabdominal paclitaxel administration and systemic S-1 therapy can be one of appropriate forms of chemotherapy for inoperable peritoneal carcinomatosis from goblet cell carcinoid of appendix.

[A long-surviving patient with lung pleomorphic carcinoma treated with postoperative carboplatin and paclitaxel combination chemotherapy].

We presented the case of a 46-year-old man with no medical or family history but with a history of smoking 3 packs of cigarettes per day for the past 25 years. He was admitted to our hospital due to hemoptysis. Chest computed tomography revealed a tumor of right upper lung and interstitial pneumonia in the surrounding lung parenchyma. He was operated upon and diagnosed with stage IIB pleomorphic carcinoma of the lung with invasion of the chest wall. He underwent three courses of postoperative carboplatin (CBDCA) (area under the curve 5 on day 1, every 3 weeks and paclitaxel(PTX) (200 mg/m(2); day 1, every 3 weeks) combination chemotherapy. No recurrence was observed for a period of 760 days after the operation. According to previous reports, lung pleomorphic carcinoma is aggressive and has a poor prognosis. Further, the significance of chemotherapy in the management of this disease has not been established. Postoperative combination chemotherapy of CBDCA and PTX may result in a good prognosis for this disease.

Beneficial effect of tacrolimus on myasthenia gravis with thymoma.

We examined the effect of tacrolimus on myasthenia gravis (MG). Five patients with thymoma and 5 patients without thymoma underwent prior thymectomy but showed persistent myasthenic symptoms. Oral administration with tacrolimus significantly improved MG scores 1, 3, and 6 months following the beginning of treatment in all patients (P < 0.05), and the improvement was significantly higher in the thymoma group compared with the nonthymoma group (P < 0.05). However, there was no significant change in antiacetylcholine receptor titers in either group. This indicates a particular application of immunosuppressive therapy for thymomatous MG following thymectomy.

Involvement of mitochondria in myasthenia gravis complicated with dermatomyositis and rheumatoid arthritis: a case report.

We report a 57-year-old male with myasthenia gravis complicated with dermatomyositis and rheumatoid arthritis without evidence of thymoma. He showed prominent muscle wasting and weakness in the four extremities and trunk in addition to swallowing disturbance. He showed intolerance to exercise on a bicycle ergometer, and muscle biopsy specimens demonstrated ragged-red fibers. An anti-acetylcholine receptor (AChR) antibody was detected in his serum but no anti-mitochondrial M2 component antibody was found. In contrast, results of immunohistochemical study indicated that his serum sample reacted to muscle mitochondria as well as AChR. These results indicate the presence of an unidentified anti-mitochondrial antibody that may be involved in the development of mitochondrial dysfunction in skeletal muscle of the present patient.