Inhibitory effect of tDCS on auditory evoked response: Simultaneous MEG-tDCS reveals causal role of right auditory cortex in pitch learning.

A body of literature has demonstrated that the right auditory cortex (AC) plays a dominant role in fine pitch processing. However, our understanding is relatively limited about whether this asymmetry extends to perceptual learning of pitch. There is also a lack of causal evidence regarding the role of the right AC in pitch learning.  We addressed these points with anodal transcranial direct current stimulation (tDCS), adapting a previous behavioral study in which anodal tDCS over the right AC was shown to block improvement of a microtonal pitch pattern learning task over 3 days. To address the physiological changes associated with tDCS, we recorded MEG data simultaneously with tDCS on the first day, and measured behavioral thresholds on the following two consecutive days. We tested three groups of participants who received anodal tDCS over their right or left AC, or sham tDCS, and measured the N1m auditory evoked response before, during, and after tDCS. Our data show that anodal tDCS of the right AC disrupted pitch discrimination learning up to two days after its application, whereas learning was unaffected by left-AC or sham tDCS. Although tDCS reduced the amplitude of the N1m ipsilaterally to the stimulated hemisphere on both left and right, only right AC N1m amplitude reductions were associated with the degree to which pitch learning was disrupted. This brain-behavior relationship confirms a causal link between right AC physiological responses and fine pitch processing, and provides neurophysiological insight concerning the mechanisms of action of tDCS on the auditory system.

Unilateral Dorsolateral Medullary Hemorrhage Presenting with Severe Dysphagia.

We report an 87-year-old woman with right dorsolateral medullary hemorrhage. She did not show all of the usual symptoms of Wallenberg syndrome and her main symptom was severe dysphagia. Dorsolateral medullary hemorrhage may be overlooked, because it is rare and does not exhibit the typical Wallenberg syndrome presentation usually seen in patients with infarction at the dorsolateral medulla.

Insights Into Auditory Cortex Dynamics From Non-invasive Brain Stimulation.

Non-invasive brain stimulation (NIBS) has been widely used as a research tool to modulate cortical excitability of motor as well as non-motor areas, including auditory or language-related areas. NIBS, especially transcranial magnetic stimulation (TMS) and transcranial direct current stimulation, have also been used in clinical settings, with however variable therapeutic outcome, highlighting the need to better understand the mechanisms underlying NIBS techniques. TMS was initially used to address causality between specific brain areas and related behavior, such as language production, providing non-invasive alternatives to lesion studies. Recent literature however suggests that the relationship is not as straightforward as originally thought, and that TMS can show both linear and non-linear modulation of brain responses, highlighting complex network dynamics. In particular, in the last decade, NIBS studies have enabled further advances in our understanding of auditory processing and its underlying functional organization. For instance, NIBS studies showed that even when only one auditory cortex is stimulated unilaterally, bilateral modulation may result, thereby highlighting the influence of functional connectivity between auditory cortices. Additional neuromodulation techniques such as transcranial alternating current stimulation or transcranial random noise stimulation have been used to target frequency-specific neural oscillations of the auditory cortex, thereby providing further insight into modulation of auditory functions. All these NIBS techniques offer different perspectives into the function and organization of auditory cortex. However, further research should be carried out to assess the mode of action and long-term effects of NIBS to optimize their use in clinical settings.

Asymmetric Interhemispheric Transfer in the Auditory Network: Evidence from TMS, Resting-State fMRI, and Diffusion Imaging.

Hemispheric asymmetries in human auditory cortical function and structure are still highly debated. Brain stimulation approaches can complement correlational techniques by uncovering causal influences. Previous studies have shown asymmetrical effects of transcranial magnetic stimulation (TMS) on task performance, but it is unclear whether these effects are task-specific or reflect intrinsic network properties. To test how modulation of auditory cortex (AC) influences functional networks and whether this influence is asymmetrical, the present study measured resting-state fMRI connectivity networks in 17 healthy volunteers before and immediately after TMS (continuous theta burst stimulation) to the left or right AC, and the vertex as a control. We also examined the relationship between TMS-induced interhemispheric signal propagation and anatomical properties of callosal auditory fibers as measured with diffusion-weighted MRI. We found that TMS to the right AC, but not the left, resulted in widespread connectivity decreases in auditory- and motor-related networks in the resting state. Individual differences in the degree of change in functional connectivity between auditory cortices after TMS applied over the right AC were negatively related to the volume of callosal auditory fibers. The findings show that TMS-induced network modulation occurs, even in the absence of an explicit task, and that the magnitude of the effect differs across individuals as a function of callosal structure, supporting a role for the corpus callosum in mediating functional asymmetry. The findings support theoretical models emphasizing hemispheric differences in network organization and are of practical significance in showing that brain stimulation studies need to take network-level effects into account.

Polarity-specific transcranial direct current stimulation disrupts auditory pitch learning.

Transcranial direct current stimulation (tDCS) is attracting increasing interest because of its potential for therapeutic use. While its effects have been investigated mainly with motor and visual tasks, less is known in the auditory domain. Past tDCS studies with auditory tasks demonstrated various behavioral outcomes, possibly due to differences in stimulation parameters, task-induced brain activity, or task measurements used in each study. Further research, using well-validated tasks is therefore required for clarification of behavioral effects of tDCS on the auditory system. Here, we took advantage of findings from a prior functional magnetic resonance imaging study, which demonstrated that the right auditory cortex is modulated during fine-grained pitch learning of microtonal melodic patterns. Targeting the right auditory cortex with tDCS using this same task thus allowed us to test the hypothesis that this region is causally involved in pitch learning. Participants in the current study were trained for 3 days while we measured pitch discrimination thresholds using microtonal melodies on each day using a psychophysical staircase procedure. We administered anodal, cathodal, or sham tDCS to three groups of participants over the right auditory cortex on the second day of training during performance of the task. Both the sham and the cathodal groups showed the expected significant learning effect (decreased pitch threshold) over the 3 days of training; in contrast we observed a blocking effect of anodal tDCS on auditory pitch learning, such that this group showed no significant change in thresholds over the 3 days. The results support a causal role for the right auditory cortex in pitch discrimination learning.

Relation between changes in foveal choroidal thickness and 1-year results of ranibizumab therapy for polypoidal choroidal vasculopathy.

AIM: To determine a correlation between changes in the subfoveal choroidal thickness and outcomes 1 year after ranibizumab therapy for polypoidal choroidal vasculopathy (PCV). METHODS: We prospectively studied 89 consecutive eyes with treatment-naïve symptomatic PCV and 1 year of follow-up after treatment. The choroidal thickness was measured monthly by optical coherence tomography using enhanced-depth imaging and the correlation between the changes in the choroidal thickness and outcomes 1 year after treatment was analysed. RESULTS: 86 eyes followed for 1 year were ultimately analysed. The mean logarithm of the minimum angle of resolution visual acuity (0.33±0.35) 1 year after the first injection significantly (p=0.001) improved compared to baseline (0.42±0.37). The mean choroidal and foveal retinal thicknesses decreased significantly (p=0.001 for both comparisons) from 271 and 347 µm to 212 and 203 µm, respectively. The amplitude of the change in the subfoveal choroidal thickness during the 1-year follow-up in eyes in which the polypoidal lesions resolved 1 year after the first injection (89±94 µm) was significantly (p=0.022) greater than in eyes in which the polypoidal lesions remained (45±109 µm). CONCLUSIONS: The subfoveal choroidal thickness decreased during ranibizumab therapy, which was associated with resolved polypoidal lesions and foveal retinal thickness, and may be associated with PCV activity.

Two-year outcomes of intravitreal bevacizumab therapy for macular oedema secondary to branch retinal vein occlusion.

AIM: To determine the 2-year outcomes of intravitreal bevacizumab (IVB) injections in eyes with macular oedema (ME) following branch retinal vein occlusion (BRVO). METHODS: Of 105 consecutive eyes (105 treatment-naïve patients) with ME following BRVO, 89 eyes were followed for 2 years after the first injection. During the 2-year follow-up period, patients were examined at least every 3 months and received an IVB injection (1.25 mg/0.05 mL) if they met prespecified retreatment criteria. Rescue grid laser was permitted based on the findings of the Branch Vein Occlusion Study. RESULTS: The baseline logarithm of the minimum angle of resolution visual acuity (VA) was 0.64±0.24 (mean±SD), which significantly (p=0.001) improved 1 month after the first injection to 0.39±0.22. One year after the first injection, VA improved significantly (p=0.001) to 0.33±0.21 and remained 0.34±0.21 until 2 years after the first injection (p=0.001). The changes in foveal thickness were correlated with those of VA during the 2-year follow-up period with a mean of 3.8±1.5 injections (including the first injection). CONCLUSIONS: This relatively large case series study showed favourable 2-year outcomes using bevacizumab to treat ME following BRVO. Bevacizumab provides substantial long-term benefits in the treatment of ME following BRVO.

Factors predictive of outcomes 1 year after 3 monthly ranibizumab injections and as-needed reinjections for polypoidal choroidal vasculopathy in Japanese patients.

PURPOSE: To determine baseline factors predictive of outcomes 1 year after 3 monthly intravitreal ranibizumab injections followed by as-needed injections for polypoidal choroidal vasculopathy. METHODS: A nonrandomized prospective 1-year trial collected data from 144 Japanese patients (144 eyes) with symptomatic polypoidal choroidal vasculopathy who received one 0.5-mg intravitreal ranibizumab injection monthly for 3 months followed by as-needed retreatments. Statistical analysis evaluated baseline independent factors predictive of better visual acuity and the need for fewer injections 1 year after the first injection. RESULTS: After the initial 3 monthly injections, a mean ± standard deviation of 1.2 ± 1.1 as-needed injections was administered. The mean visual acuity improved significantly (P < 0.01) from 20/80 to 20/50. Better visual acuity and no history of photodynamic therapy or clusters of grape-like polypoidal lesions were significant independent baseline factors predictive of better visual acuity 1 year after the first injection. No factors were significantly associated with a need for fewer ranibizumab reinjections during follow-up. CONCLUSION: The baseline clinical characteristics predicted favorable visual acuity outcomes. These findings might be useful to explaining the prognosis of ranibizumab treatment to the patients with polypoidal choroidal vasculopathy.

Results of 2 years of treatment with as-needed ranibizumab reinjection for polypoidal choroidal vasculopathy.

PURPOSE: To investigate the 2-year outcomes of three monthly intravitreal ranibizumab injections followed by as-needed reinjections to treat polypoidal choroidal vasculopathy (PCV). METHODS: Seventy-five consecutive eyes with naïve symptomatic PCV with 2 years of follow-up after treatment were studied prospectively. RESULTS: The mean (±SD) numbers of injections were 4.2±1.3 that included three monthly injections in the loading phase and 1.6±1.7 during years 1 and 2, respectively (mean 2-year total, 5.6±1.9). The baseline logarithm of the minimum angle of resolution visual acuity (VA) was 0.59±0.51 that improved significantly (p=0.001 for both comparisons) to 0.37±0.33 and 0.41±0.40 at 1 and 2 years, respectively, after the first injection. Although no significant difference was found between years 1 and 2 after the first injection, the VA tended to decrease slightly during year 2. The improved foveal thickness was maintained during year 2. Thirty (40%) eyes and 19 (25%) eyes, respectively, at years 1 and 2 after the first injection had no polypoidal lesions on indocyanine green angiography. A branching vascular network (BVN) remained in all eyes 2 years after the first injection and tended to increase in size during year 2. CONCLUSIONS: The 2-year outcomes showed significant VA and foveal thickness improvements in eyes with PCV. During year 2, the magnitude of the improvement was lower compared with year 1. An as-needed reinjection schedule might not prevent polypoidal lesions or BVNs from regrowing. Further investigations should establish a treatment strategy for PCV.

Role of FK506 binding protein 5 (FKBP5) in osteoclast differentiation.

OBJECTIVES: We previously disclosed the enhanced expression of FK506 binding protein 5 (FKBP5) messenger RNA (mRNA) in bone marrow (BM) CD34(+) cells in rheumatoid arthritis (RA), in which systemic osteoporosis takes place. Since BM CD34(+) cells are precursors of osteoclasts, it is possible that FKBP5 overexpression might lead to osteoporosis by affecting osteoclastogenesis. We therefore explore the influences of FKBP5 in osteoclast differentiation. METHODS: Stable transfectants of RAW264.7 overexpressing murine FKBP5 gene were established. Osteoclast differentiation was induced by receptor activator of nuclear factor kappa B (NF-κB) ligand and was evaluated by tartrate-resistant acid phosphatase (TRAP) staining and pit formation assay. RESULTS: FKBP5 transfectants of RAW264.7 generated higher numbers of TRAP-positive multinucleated cells with increased activity of pit formation on calcium phosphate-coated culture slides than mock transfectants. The enhancement of osteoclast differentiation of FKBP5 transfectants was only partially inhibited by N-acetyl L-cysteine. Finally, glucocorticoid enhanced FKBP5 mRNA expression as well as osteoclast differentiation of RAW264.7 cells in a dose-dependent manner. CONCLUSIONS: These results indicate that FKBP5 promotes osteoclast differentiation by a mechanism distinct from NF-κB activation. Moreover, the data suggest that FKBP5 might play a role in bone destruction and development of osteoporosis in RA as well as in glucocorticoid-induced osteoporosis.

One-year results of three monthly ranibizumab injections and as-needed reinjections for polypoidal choroidal vasculopathy in Japanese patients.

PURPOSE: To investigate the 1-year outcomes of monthly intravitreal injections of ranibizumab for 3 months followed by an as-needed reinjection schedule to treat polypoidal choroidal vasculopathy (PCV) in Japanese patients. DESIGN: Prospective, consecutive case series. METHODS: Eighty-five eyes of 82 consecutive Japanese patients with naïve symptomatic PCV received monthly intravitreal injections of ranibizumab for 3 months followed by an as-needed reinjection schedule. Eighty-one eyes (95%) followed for 1 year were studied. RESULTS: A mean of 4.2 ± 1.3 (mean ± standard deviation) injections were administered over 1 year. Twenty-three of 81 eyes (28%) did not require additional injections and 32 eyes (40%) required only 1 injection after the 3 monthly injections. The mean (± standard error) logarithm of minimal angle of resolution (logMAR) visual acuity (VA) at baseline was 0.59 ± 0.37 and improved to 0.37 ± 0.30 (P = .001). Thirty eyes (37%) and 5 eyes (6%), respectively, had improved and decreased VA of 0.3 or more logMAR unit. Indocyanine green angiography showed that the polypoidal lesions resolved in 21 eyes (26%) and 32 eyes (40%) 3 months and 1 year after the first injection, respectively. Abnormal choroidal vessels remained in all eyes. CONCLUSIONS: Monthly injections of ranibizumab for 3 months to treat PCV improved the VA, and a reinjection schedule based on need maintained the improved VA. The polypoidal lesions tended to improve over 1 year, whereas abnormal choroidal vessels remained in all eyes. Further long-term follow-up is needed to determine the efficacy of ranibizumab therapy for PCV.

Incidence of retinal breaks in eyes undergoing 23-gauge or 20-gauge vitrectomy with induction of posterior vitreous detachment.

PURPOSE: To compare the incidence rates of retinal breaks in eyes in which posterior vitreous detachment was induced during 23-gauge and 20-gauge vitrectomies to treat macular holes or preretinal membranes. METHODS: We retrospectively reviewed 122 eyes of 115 patients with a macular hole or preretinal membrane who underwent induction of posterior vitreous detachment during 23-gauge vitrectomy (23-gauge group) and 61 eyes of 58 consecutive patients with the disorders who underwent induction of posterior vitreous detachment during 20-gauge vitrectomy performed by 1 surgeon. RESULTS: No difference was found in the incidence rates of intraoperative retinal breaks between the 23-gauge (16% [20/122]) and 20-gauge (16% [10/61]) groups. A postoperative rhegmatogenous retinal detachment developed in 2 (2%) eyes in the 23-gauge group, whereas no eyes in the 20-gauge group had postoperative retinal breaks or rhegmatogenous retinal detachment. The incidence rates of retinal breaks in eyes with a macular hole and preretinal membrane did not differ significantly. CONCLUSION: Posterior vitreous detachment induced during vitrectomy frequently results in intraoperative retinal breaks, the incidence of which may be independent of the gauge of the vitreous instruments. Surgeons should be alert to the development of retinal breaks.

Surgical outcomes of 23- and 20-gauge vitrectomies for rhegmatogenous retinal detachment associated with posterior vitreous detachment.

BACKGROUND AND OBJECTIVE: To compare the outcomes of 23- and 20-gauge vitrectomies 1 year after primary repair of rhegmatogenous retinal detachments (RRDs) associated with a posterior vitreous detachment (PVD). PATIENTS AND METHODS: One hundred seventy-five consecutive eyes were reviewed that had undergone 23- or 20-gauge vitrectomy for RRDs associated with PVD. RESULTS: Retinal reattachment during the year after the first vitrectomy occurred in 88 (91%) of 97 eyes in the 23-gauge group and 70 (90%) of 78 eyes in the 20-gauge group. All eyes in both groups achieved anatomic success after another procedure. The surgical time in the 23-gauge group was significantly (P = .03) shorter than in the 20-gauge group. No significant difference was found between the preoperative and postoperative visual acuities in both groups. CONCLUSION: Twenty-three-gauge vitrectomy can obtain anatomic and visual acuity results similar to those obtained with 20-gauge vitrectomy after primary repair of RRDs and may be a surgical option for treating the disorder.

23- and 20-gauge vitrectomy with air tamponade with combined phacoemulsification for idiopathic macular hole: a single-surgeon study.

PURPOSE: To compare the results of 23- and 20-gauge vitrectomies combined with phacoemulsification and aspiration and intraocular lens implantation (phacoemulsification surgery) 1 year after repair of idiopathic macular holes. DESIGN: Retrospective, consecutive, comparative case series. METHODS: The medical charts of 100 consecutive eyes were reviewed that had undergone either 23- or 20-gauge vitrectomy combined with phacoemulsification surgery to treat an idiopathic macular hole performed by 1 surgeon. The rate of improvement of the logarithm of the minimal angle of resolution visual acuity (VA) was calculated using the formula: (postoperative value - preoperative value) × 100/(1-year postoperative value - preoperative value). RESULTS: The macular holes closed successfully after the primary vitrectomy in all eyes in both groups. Although the VAs did not differ significantly before surgery or 1 year after surgery between the 2 groups, the VA improvement was significantly greater 1 and 3 months after surgery (P = .02, for both) in the 23-gauge group compared with the 20-gauge group. The induced corneal astigmatism levels 1 week and 1 and 3 months after surgery were significantly lower (P = .01, P = .01, and P = .03, respectively) and the surgical time was significantly shorter (P = .01) in the 23-gauge group than in the 20-gauge group. No apparent complications developed in either group. CONCLUSIONS: Since 23-gauge vitrectomy combined with phacoemulsification surgery is advantageous because the VA improved rapidly after treating the macular holes with an acceptable safety profile, idiopathic macular holes are a good indication for 23-gauge vitrectomy combined with phacoemulsification surgery.

Factors predictive of visual acuity outcomes 1 year after photodynamic therapy in Japanese patients with polypoidal choroidal vasculopathy.

PURPOSE: The purpose of this study was to determine the factors predictive of visual acuity (VA) outcomes 1 year after photodynamic therapy (PDT) for polypoidal choroidal vasculopathy. METHODS: We prospectively studied 220 eyes of 210 Japanese patients with polypoidal choroidal vasculopathy treated with primary application of PDT. A stepwise logistic regression model was used to estimate the independent factors predictive of better VA and improvement of VA 1 year after the primary PDT. RESULTS: Visual acuities at the various follow-up evaluations improved significantly compared with baseline (P = 0.001 for all comparisons). The VA improved and decreased more than 0.3 logarithm of minimum angle of resolution unit 1 year after the primary PDT in 55 (25%) and 21 (10%) eyes, respectively. Stepwise logistic regression analysis showed that younger age, smaller greatest linear dimension, better baseline VA, and less baseline hemorrhage were significant and independent factors predictive of better VA 1 year after PDT, and younger age, smaller greatest linear dimension, better baseline VA, less hemorrhaging, and the presence of a serous macular detachment at baseline were significant and independent factors predictive of VA improvement. CONCLUSION: Photodynamic therapy stabilized eyes anatomically and functionally. Clinical characteristics at baseline were predictors of favorable VA outcomes after PDT. These findings may help establish the strategy of treatment for polypoidal choroidal vasculopathy.

Improvement of angiographic findings of polypoidal choroidal vasculopathy after intravitreal injection of ranibizumab monthly for 3 months.

PURPOSE: To evaluate the efficacy of 1 intravitreal injection of ranibizumab monthly for 3 months in eyes with polypoidal choroidal vasculopathy (PCV), with attention to changes on indocyanine green angiography (ICGA) with confocal scanning laser ophthalmoscopy (cSLO). DESIGN: Prospective, consecutive case series. METHODS: Fifty consecutive eyes of 50 patients with symptomatic PCV who had not been treated previously received 1 intravitreal injection of 0.5 mg ranibizumab monthly for 3 months. Changes in ICGA findings with cSLO 3 months after the primary injection were evaluated. RESULTS: The mean visual acuity (VA) at baseline (0.25; range, 0.1-0.8) improved to 0.38 (P = .001) 3 months after the primary injection. Nineteen eyes (38%) had an improvement in VA of 0.3 or more logMAR unit, and 5 eyes (10%) had a decrease in VA of 0.3 or more logMAR unit. Polypoidal lesions disappeared on ICGA in 13 eyes (26%) and the number of lesions decreased but did not disappear in 26 eyes (52%), with absorption of the accompanying fluid on optical coherence tomography. The remaining 11 eyes (22%) had unchanged or worsened polypoidal lesions. A branching vascular network remained in all 48 eyes in which the network was detected at baseline. Although resolution of the branching vascular networks or decreased diameter of the branching vascular network occurred in 11 eyes (23%), the branching vascular network was unchanged or worse in 37 eyes (77%). CONCLUSION: Although a limitation of this study is the short-term follow-up, polypoidal lesions tended to respond to ranibizumab therapy, but the branching vascular network responded poorly.

Comparison of one-year outcomes between 23- and 20-gauge vitrectomy for preretinal membrane.

PURPOSE: To compare the outcomes of transconjunctival sutureless 23-gauge vitrectomy and conventional 20-gauge vitrectomy 1 year after removal of preretinal membrane. DESIGN: Retrospective, consecutive, comparative case series. METHODS: One hundred consecutive eyes with a preretinal membrane underwent either 23- and 20-gauge vitrectomy. The rate of improvement of the logarithm minimum angle of resolution visual acuity (VA) was calculated by the formula: (various postoperative values-preoperative values) x 100/ (1 year postoperative values-preoperative values). RESULTS: No significant differences were found between the groups in the preoperative and postoperative VAs. The VA improvement was higher and the surgically induced corneal astigmatism was lower 1 week postoperatively in the 23-gauge group compared with the 20-gauge group (P = .006 and P = .001, respectively). The flare values in the anterior chamber measured by laser flare meter preoperatively and 1 week postoperatively did not differ between the groups. The surgical time was significantly (P = .023) shorter in the 23-gauge group than in the 20-gauge group. No apparent complications developed in either group. CONCLUSION: Transconjunctival sutureless 23-gauge vitrectomy appears effective for preretinal membrane surgery with an acceptable safety profile. Transconjunctival sutureless 23-gauge vitrectomy may be a treatment option for preretinal membranes.

Causes of macular serous retinal detachments in Japanese patients 40 years and older.

PURPOSE: To investigate the causes of macular serous retinal detachment without hemorrhage at the macula in patients 40 years and older. METHODS: Seventy-one eyes of 71 consecutive Japanese patients 40 years and older with the disease were examined using optical coherence tomography, digital simultaneous fluorescein and indocyanine green angiographies with a confocal laser scanning system. RESULTS: Of 71 eyes, 17 eyes (24%) had central serous chorioretinopathy, including three eyes with chronic central serous chorioretinopathy, 40 eyes (56%) had polypoidal choroidal vasculopathy (PCV), 10 eyes (14%) had occult choroidal neovascularization secondary to age-related macular degeneration, one had Harada disease, and another had retinal macroaneurysms. In two eyes, the diagnosis could not be established because of difficulty differentiating among chronic central serous chorioretinopathy, PCV, and occult choroidal neovascularization. Thirty-eight of 59 (64%) eyes of patients in the sixth decade of life and older had PCV. CONCLUSIONS: Polypoidal choroidal vasculopathy is a primary cause of macular serous retinal detachment without hemorrhage in Japanese patients over 50 years of age. Since clinical and fluorescein angiographic findings are indistinguishable among central serous chorioretinopathy, PCV, and occult choroidal neovascularization, indocyanine green angiography might help to establish a more definitive diagnosis.

Henoch-Schönlein pupura complicated by perforation of the gallbladder.

Henoch-Schönlein purpura is a systemic vasculitis of small vessels characterized by purpura, arthralgias, glomerulonephritis and gastrointestinal involvements which can cause intestinal perforation. A 75-year-old man with renal dysfunction and palpable purpura (petechiae) of which dermal specimen showed leukocytoclastic vasculitis was diagnosed as Henoch-Schönlein purpura. Corticosteroid and cyclosporine were effective, but subsequently he developed pneumocystis pneumonia. After he improved by treatment with trimethoprim-sulfamethoxazole, he presented sudden abdominal pain, caused by perforation of the gallbladder. Histological analysis revealed infiltration of inflammatory cells with bleeding in the gallbladder wall at the site of perforation. It is suggested that inflammatory disruption of capillary walls might lead to the perforation of the gallbladder.

Reversible focal neurological deficits in systemic lupus erythematosus: report of 2 cases and review of the literature.

We report two cases presenting focal neurological deficits with high intensity lesions in fluid attenuated inversion recovery (FLAIR) images on brain magnetic resonance imaging (MRI), which almost completely improved by corticosteroid therapy. Marked elevation of cerebrospinal fluid IL-6 was also noted when these patients showed neurological deficits. As far as we explored, there have been thirteen published case reports of systemic lupus erythematosus patients with reversible focal neurological deficits. The neurological symptoms varied from case to case, but could be attributed to the lesions on MRI scans. The completely reversible feature of neurological manifestations as well as MRI findings on corticosteroid therapy is distinct from any other disorder, including cerebrovascular disease and demyelinating syndrome, in the 1999 American College of Rheumatology nomenclature. Therefore, we propose that reversible focal neurological deficits should be added to the 1999 nomenclature and classification and case definitions.