[Simultaneous bilateral pneumothorax complicating Pneumocystis carinii pneumonia in a homeless man with AIDS].

Although pneumothorax is a well-known complication of AIDS related Pneumocystis carinii pneumonia, simultaneous bilateral pneumothorax has not been reported in Japan. A 54-year-old homeless man was admitted with emaciation and dyspnea. Chest X-ray showed diffuse ground glass opacity. Computed tomography of the chest demonstrated ground glass opacity and cyst-like lesions in both upper lobes of the lung. The patient was HIV positive. Grocott's stain of a bronchial lavage specimen demonstrated Pneumocystis carinii microorganisms. Intravenous trimethoprim-sulfamethoxazol and steroid administration was started. Seven days later, the patient developed tension pneumothorax of the right lung. Immediately after the thoracostomy, contralateral pneumothorax developed. Another chest tube was inserted. Subsequently, the patient died from bilateral pneumothorax. The endemicity of HIV infections among the homeless population is already a significant problem in Western countries. We should be aware that HIV infection may become a problem among the Japanese homeless as well.

[Multiple cavitary pulmonary metastases from ovarian cancer: a case report].

Cavitation in pulmonary metastases is thought to be uncommon. To date, few cases of pulmonary metastases originating from ovarian cancer and showing cavitation have been reported. We report a patient with multiple cavitation in pulmonary metastases from ovarian mucinous cystadenocarcinoma. A 28-year-old woman was admitted to our hospital presenting with cough and fever. The patient had undergone right ovariectomy for ovarian mucinous cystadenocarcinoma at the age of 23 years. Her chest radiograph on admission showed multiple cavities associated with infiltration in both lungs. Histological sections obtained by transbronchial lung biopsy revealed mucus-secreting adenocarcinoma, and a diagnosis of metastatic lung cancer from the ovary was made. Computed tomographic (CT) scans of the chest demonstrated various findings, including multiple thick-walled cavities, thin-walled cavities, air-space consolidations, ground glass opacities, and centrilobular nodular shadows formed by aspiration of the mucinous secretions. It is important to recognize that cavitation can occur in pulmonary metastases from ovarian cancer.

[Cave-associated acute pulmonary histoplasmosis in two Japanese returning from Mexico].

We report cases of cave-associated acute pulmonary histoplasmosis that occurred in two Japanese returning from Yucatan, Mexico. Patient 1 is a 35-year-old woman who worked in a bat-infested cave in Mexico for about 3 weeks. Almost all her colleagues had developed cough, fever and headache after 5 days in the cave. She was asymptomatic but her chest radiograph showed multiple nodules 5-10 mm in diameter throughout both lungs. The histoplasmal mycelial-phase complement fixation titer on admission was 1:16, and 1:128 one month later. Patient 2, the 53-year-old husband of patient 1, was also infected by histoplasma in the cave, and similar nodules were observed in his chest radiograph. His histoplasmal complement fixation titer did not elevate. To date, about 20 cases of pulmonary histoplasmosis have been reported in Japan. The number of imported mycoses in Japan is increasing, and histoplasmosis should be considered in the differential diagnosis of pulmonary nodules in travelers returning from endemic areas.

Primary intracerebral and aneurysmal subarachnoid hemorrhage in Izumo City, Japan. Part I: incidence and seasonal and diurnal variations.

OBJECT: The purpose of this community-based study was first to estimate the incidence rates of primary intracerebral hemorrhage (ICH) and aneurysmal subarachnoid hemorrhage (SAH) in Izumo City, Japan, and second to investigate whether there were seasonal and diurnal periodicities in their onset. METHODS: During 1991 through 1996, 267 patients with primary ICH and 123 with aneurysmal SAH were treated in Izumo City. The crude and the age- and sex-adjusted annual incidence rates per 100,000 population for all ages were 52 and 48 for ICH and 24 and 23 for SAH, respectively. These incidence rates were higher than those previously published for any other geographical region. The incidence rates of both ICH and SAH increased almost linearly with age. For ICH, a significant seasonal pattern was observed in men and in patients younger than 65 years, with a peak in winter and a trough in summer. However, no significant seasonal fluctuation was found in women or in individuals aged 65 years or older. There was no significant seasonal periodicity for SAH, even when patients were analyzed according to sex and age. Diurnal variations in the onset of both ICH and SAH were significant (except in men with SAH), with a nadir between midnight and 6:00 a.m. CONCLUSIONS: The actual incidence rates of both primary ICH and aneurysmal SAH seem to be much higher than have been reported so far. In addition, the data indicate the existence of seasonal periodicity for men and younger patients with ICH, and that the risk of both ICH and SAH is lower during nighttime.

[Outbreak of hepatitis A virus infection among men who have sex with men].

We have recently encountered an outbreak of hepatitis A in Tokyo. Between July 1998 and November 1999, 21 patients were treated at our hospital. They were all male and 18 patients (86%) had had sex with men (MSM). About a half of the patients were seropositive for syphilis, hepatitis B and HIV. The VP1/2A region could be amplified by nested PCR in 6 of the 21 patients. They had the same sequences and were grouped into genotype IA. Homosexual activity should be kept in mind as a leading risk factor for hepatitis A in the recent Japanese population.

[Two cases with coil embolization following incomplete neck clipping].

We report two cases with embolization (coil embolization) using Guglielumi detachable coils of residual aneurysms following incomplete neck clipping. The first case, a 75-year-old woman suffered from a subarachnoid hemorrhage due to the rupture of a left internal carotid posterior communicating aneurysm in June, 1997. Neck clipping of the aneurysm was performed at day 1. Follow-up angiogram at day 7 showed a residual aneurysm involving the dome of the initial aneurysm. We performed coil embolization of the residual aneurysm following the angiogram. Almost complete obliteration of the aneurysm lasted during the follow-up period of two and a half years. The second case, a 71-year-old woman suffered from a subarachnoid hemorrhage due to the rupture of a right internal carotid posterior communicating aneurysm in May, 1999. Neck clipping of the aneurysm was performed at day 1. Follow-up angiogram at day 7 showed a residual aneurysm involving only a part of the initial aneurysm near the neck. Because no spontaneous thrombosis of the residual aneurysm was obtained after 2 months, we performed coil embolization of the residual aneurysm. Almost complete obliteration of the aneurysm lasted during the follow-up period of 7 months. These patients were discharged with good performance status. We consider the morphologic feature of the residural aneurysm to be most important for determining when to perform coil embolization of such residual aneurysms.

[Pneumonia among the homeless].

Although there are some studies concerning tuberculosis among the homeless persons in Japan, almost no detailed analysis is available about non-tuberculous lung infections in this population. We retrospectively studied the clinical features and microbial etiology of pneumonia among the homeless. This series included twenty so-called homeless persons, 19 male and one female, who were admitted to our hospital with a clinical diagnosis of pneumonia from April 1993 to July 1996. The average age was 56 years-old. All patients were transferred by ambulance. Most of them were admitted night in the winters, and had respiratory failure together with other serious complications such as gastrointestinal disease, liver failure and cerebrovascular disease. Chest X ray revealed so-called lobar pneumonia in 8 of 20 cases (40%). Microbial etiologic agents were found in 14 patients (70%). Pneumococcus amounted to 80% of all the speculated pathogens. Despite intensive care after admission, 6 of 20 patients (30%) died subsequently. Although fatal pneumococcal pneumonia were reported to have decreased in the general population in Japan, morbidity and mortality of pneumococcal pneumonia was very high in this series.

Ruptured de novo aneurysm induced by ethyl 2-cyanoacrylate: case report.

OBJECTIVE AND IMPORTANCE: We report a rare case of a ruptured de novo aneurysm induced by ethyl 2-cyanoacrylate. CLINICAL PRESENTATION: A 44-year-old woman had undergone microvascular decompression for a right-sided facial spasm. The preoperative vertebral angiogram did not show any aneurysmal dilation. The right anteroinferior cerebellar artery, which was compressing the exit zone of the facial nerve, was detached and fixed to the dura mater with ethyl 2-cyanoacrylate. Nine years later, the patient suffered a subarachnoid hemorrhage caused by the rupture of a newly developed aneurysm of the right anteroinferior cerebellar artery. INTERVENTION: The aneurysm was clipped 2 days after onset of the subarachnoid hemorrhage. It consisted of two bulges in the arterial wall on the proximal side of the meatal loop. One bulge was stuck to the dura mater of the pyramis by ethyl 2-cyanoacrylate, which had been used in the microvascular decompression 9 years previously. CONCLUSION: This is the first reported clinical case of a de novo aneurysm induced by a cyanoacrylate adhesive. Ethyl 2-cyanoacrylate can damage the arterial wall and induce a de novo aneurysm.

An acyclic monoterpene glucosyl ester from Lantana lilacia.

A new acyclic monoterpene glucosyl ester was isolated from the leaves of Lantana lilacia together with the known compound, acteoside. The structure of the new compound was elucidated by spectroscopic and chemical analyses.

[Pulmonary Kaposi's sarcoma in a patient with the acquired immunodeficiency syndrome].

Cutaneous Kaposi's sarcoma (KS) is a well-known manifestation of the acquired immunodeficiency syndrome, but pulmonary KS is very rare in Japan. We encountered a 27-year-old Japanese, homosexual man who had extensive pulmonary KS. He came to our hospital because of a cough and dyspnea. On admission, there were some small nodules on the skin, and examination of a biopsy specimen led to the diagnosis of KS. The test for the human immunodeficiency virus antibody was positive and the CD4+ cell count was 69 per cubic millimeter. A radiograph of the chest showed multiple diffuse nodules, linear opacities, and some pleural effusion. Computed tomography also revealed multiple nodules and linear densities distributed along the bronchovascular bundles. Bronchoscopic examination revealed diffuse erythematous changes of the bronchial mucosa with some red polypoid lesions, which was compatible with endobronchial KS. Hypoxia developed one month after bronchoscopy. Two courses of chemotherapy with bleomycin and vincristine were given, and resulted in temporary improvement. A definite diagnosis of KS was made by necropsy.

[A case of multiple cerebral arteriovenous malformations treated by gamma knife radiosurgery].

We reported a case of multiple cerebral arteriovenous malformations (AVMs) treated by gamma knife radiosurgery. A 6-year-old girl was admitted because of systemic tonic convulsion. At the first admission, we performed only vertebral angiography, which showed a 15 mm cerebral AVM. It was fed by the right posterior cerebral artery and drained into the great vein of Galen. Seven years after the first admission, the patient returned again with severe headache. Four-vessel cerebral angiograms showed another 7 mm AVM fed by the left frontopolar artery. We treated both cerebral AVMs bv gamma knife radiosurgery. Follow-up angiograms performed 2 years after radiosurgery confirmed the disappearance of both AVMs. We then discuss treatment of multiple cerebral AVMs.

A case of AIDS-related hepatic Kaposi's sarcoma.

In Japan, Kaposi's sarcoma (KS) is a very rare neoplasm. However, it does occur as one of the complications in patients with acquired immunodeficiency syndrome (AIDS). AIDS-related KS commonly involves the skin, lymph nodes, and gastrointestinal tract. Hepatic KS is sometimes observed in AIDS patients at autopsy, but it is very rarely diagnosed during life. We report a case of hepatic KS in an AIDS patient, detected by ultrasonography (US), computed tomography (CT), and magnetic resonance imaging (MRI) during life and proven at autopsy. Abdominal US revealed multiple hyperechoic tumors along the portal vein. CT scan showed low density and delayed enhancement by contrast material. These tumors were revealed as a low intensity area on a T1-weighted image of MRI and as a high intensity area on T2-weighted and proton density images. US, CT scan, and MRI revealed characteristic findings of hepatic KS. These procedures are very useful for the diagnosis of hepatic KS. To our knowledge, this is the first report of hepatic KS in Japan.

Spontaneous disappearance of an aneurysmal malformation of the vein of Galen.

We describe spontaneous disappearance of an aneurysmal malformation of the vein of Galen (AMG), an anomaly that occurs most often in children, with a high mortality due to the accompanying severe cardiac failure. Spontaneous thrombosis of an AMG is rare. In this case, the AMG has been closed for about 5 years, without radiological evidence of thrombosis, and no active treatment. Proposed mechanisms of spontaneous thrombosis include slow flow shunts and severe obstruction of the venous outflow. However, in this case, the disappearance of the AMG without evidence of thrombosis indicates a different mechanisms, namely, obstruction of the feeding artery.

Secretion of growth hormone (GH)-releasing hormone by GH-producing pituitary adenoma assessed by cell immunoblot analysis.

To detect growth hormone-releasing hormone (GHRH) secreted by monodispersed human GH-producing pituitary adenoma cells, the cell immunoblot assay was performed. GHRH-secreting cells were observed in 3 cases of GH-producing pituitary adenomas. The incidence of GHRH-secreting cells in the total cell populations was 0.24-3.42%. By contrast, no GHRH-secreting cells were observed in 2 cases of clinically nonfunctioning pituitary adenomas. The findings obtained by immunohistochemical studies for adenohypophysial hormones and for nuclear antigens of proliferative activity revealed that the incidence of GHRH-secreting cells is more related to the frequency of GH cells than to the proliferative activity in GH-producing pituitary adenomas.

Effect of angiogenesis inhibitor TNP-470 on vascular formation in pituitary tumors induced by estrogen in rats.

TNP-470 (TNP), an analog of fumagillin, inhibits cell proliferation and tumorigenesis in estrogen-induced pituitary tumors in rats. This study found that treatment with TNP or TNP and bromocriptine suppressed vascular formation in these pituitary tumors more than bromocriptine alone. TNP had a greater suppressive effect on vascular formation in pituitary tumors than in normal pituitary gland. Laminin and basic fibroblast growth factor (FGF) were detected around new blood vessels in normal pituitary gland and pituitary tumor. TNP did not completely suppress laminin or basic FGF expression. The effect of TNP on pituitary tumor may involve inhibition of vascular formation by mechanisms mediated by other factors in addition to basic FGF. Treatment with bromocriptine and TNP acts indirectly and directly on vascular formation and may provide a useful chemotherapeutic modality for pituitary tumors.

Pituitary function in patients with Rathke's cleft cyst: significance of surgical management.

The pituitary function of patients with Rathke's cleft cyst before and after surgery was investigated to clarify the significance of surgery and operative indications. The authors have treated 19 patients with Rathke's cleft cyst. There were panhypopituitarism in 2 patients (11%), amenorrhea and/or galactorrhea in 3 (16%), diabetes insipidus in 4 (21%), and visual disturbance in 9 (47%). All the patients underwent systematic endocrinological examination and were found to have various degrees of pituitary dysfunction. Panhypopituitarism was endocrinologically confirmed in 2 patients. Hyperprolactinemia was observed in 4. These patients underwent aspiration of the cyst contents and biopsy of the cyst wall. Postoperative follow-up endocrinologic evaluation performed more than 3 months after surgery showed improvement in pituitary function in 9 out of 13 patients (69%). Amenorrhea and/or galactorrhea recovered or improved in 100% of patients and visual disturbance improved in 89%. However, diabetes insipidus and panhypopituitarism did not improve postoperatively, in any patient. The results of the present study indicate that the incidence of pituitary dysfunction in patients with Rathke's cleft cyst is higher than suspected and in most cases surgical intervention improves pituitary function and the clinical status of the patient. Therefore, surgical treatment is recommended even when the patient has only mild symptoms or signs, including pituitary dysfunction, to prevent irreversible panhypopituitarism.

Embolisation of orbital varix.

A 34-year-old man with intermittent exophthalmos, found to have a large varix in the right orbit, was treated by endovascular surgery. Percutaneous transfemoral venous catheterisation and embolisation of the orbital varix was performed on two occasions. A Tracker 18 microcatheter was introduced through the right inferior petrosal sinus, cavernous sinus, superior ophthalmic vein and then into the varix, following a guidewire. Superselective venography of the right ophthalmic vein showed the varix. A total of 204 platinum microcoils was used to pack the varix. At the time of discharge, the exophthalmos had largely resolved. As this technique is much less invasive than surgical resection, we recommend an attempt at endovascular embolisation of orbital varices prior to surgical removal.

A case of Cushing's disease accompanied by Rathke's cleft cyst: the usefulness of cavernous sinus sampling in the localization of microadenoma.

A 42-year-old man presented with classical symptoms of Cushing's disease. Endocrinological examinations indicated the presence of a adrenocorticotropin-(ACTH) producing pituitary adenoma. Magnetic resonance imaging showed a cystic sellar lesion, which had features of a Rathke's cleft cyst, whereas the adenoma was not depicted. The ratio of blood ACTH concentration between cubital vein, left, and right cavernous sinus was 1: 1.4: 20. During transsphenoidal surgery, in addition to the Rathke's left cyst, a tiny adenoma was detected beneath the left pituitary lobe. Cavernous sinus sampling is a useful auxiliary in the localization of an ACTH-producing adenoma, as in this case.