[A case of TSS complicated with SSSS in an adult with liver cirrhosis].

This paper reports a case of TSS complicated with SSSS in an adult with liver cirrhosis. A 52-year-old male, heavy drinker, was referred to our clinic complaining lumbago and painful swelling of the right arm. The patient had peeling of the skin over the hips, knees and elbows with positive Nikolsky's sign. The patient was in a state of shock on admission. Pyrexia persisted for 4 days and finally the body temperature rose up to 39 degrees C. The laboratory studies revealed hypoxia, DIC and multiple organ failure, and these became progressively worse. He died 4 days after admission. According to the criteria, he was diagnosed as TSS, and TSST-1 was detected from his serum. Staphylococcus aureus, coagulase type V was cultured both from the blood and from the wound of his right middle finger. This isolated strain did not produce TSST-1. The skin specimen at autopsy showed that the cleavage plane lied at the subcorneal region and close to the granular layer, with specific changes caused by exfoliative toxin. It was compatible to the exfoliation which was caused by exfoliative toxin produced from the S. aureus coagulase type V. The autopsy also revealed alcohol liver injury, liver cirrhosis and multiple organ failure due to shock state. SSSS is rare in adults, to our knowledge this is the first reported case of TTS complicated with SSSS.

[A case of coronary artery bypass grafting in a patient with active systemic lupus erythematosus].

A 59-year-old female was admitted to our hospital because of chest pain. Coronary angiography revealed severe obstruction of the left coronary artery. The findings of hematology and renal biopsy were interpreted as showing active systemic lupus erythematosus (SLE). Coronary artery bypass grafting was performed before steroid therapy because of worsening cardiac function due to myocardial ischemia. Postoperative course had been satisfactory immediately after operation, but the patient showed pulmonary infection about two months after operation and died three months after surgery. In open heart surgery for a patient with active SLE, special care must be taken to the prevention and treatment for infection.

[Occlusion of the right pulmonary artery due to acute dissecting aortic aneurysm].

A 58-year-old female was admitted with an abrupt onset of chest and back pain. The CT scan of the chest showed aortic dissection of the ascending aorta and proximal aortic arch, but the false lumen of the aortic dissection had already been occluded by a blood clot. After admission, she complained of chest pain with hemoptysis and presented facial edema and the distention of the neck veins. The pulmonary angiogram showed complete occlusion of the right pulmonary artery at the proximal segment. These findings were interpreted as pulmonary embolism. She was treated with intravenous heparin and urokinase, but these treatments did not demonstrate any improvement. She underwent a surgical exploration on the fourth hospital day. During surgery, the right pulmonary artery was discovered to be compressed and occluded by the large dissecting aneurysm of the ascending aorta. In addition, hematoma was seen between the right pulmonary artery. The ascending aorta and pulmonary trunk, which was injured in the operative procedure, were replaced with an artificial graft successfully. Postoperative pulmonary angiogram showed no stenosis of right pulmonary artery. The occlusion of the pulmonary artery by an acute dissecting aneurysm is an extremely rare complication and it is often wrongly diagnosed as pulmonary embolism. In such cases, the correct diagnosis and prompt surgical treatment is essential and antithrombolytic and anticoagulant therapy should be avoided.

[Aneurysm of the left sinus of Valsalva producing obstruction of the left main coronary artery and aortic regurgitation].

A 50-year-old male was admitted with dyspnea on exertion and palpitation. On physical examination, a grade 2/6 aortic regurgitant murmur was heard at the left sternal border. A chest roentogenogram showed an oval shadow on the left cardiac border. Digital subtraction angiogram, aortogram and coronary arteriogram revealed an unruptured-large aneurysm of the left sinus of Valsalva, which compressed the left main coronary artery and produced aortic regurgitation. Surgical correction consisted of obliteration of the orifice of the aneursym with woven Dacron graft patch, aortic valve replacement using SJM23A, and a saphenous vein bypass from the ascending aorta to the left anterior descending coronary artery. Postoperative studies showed complete obliteration of the orifice of the aneurysm, a patent aorto-coronary bypass graft and no perivalvular leakage. This aneurysm was considered congenital in origin, because of no inflammatory and infectious evidence, negative serologic test for syphilis and no aneurysmal dilatation of the ascending aorta.

Left recurrent laryngeal nerve palsy associated with primary pulmonary hypertension and patent ductus arteriosus.

Two patients with left recurrent laryngeal nerve paralysis in association with pulmonary artery hypertension are described. One had primary pulmonary hypertension and the other had patent ductus arteriosus. The greatly dilated pulmonary artery in these patients resulted in compression of the left recurrent laryngeal nerve and produced a cardiovocal (Ortner's) syndrome. The pathogenesis of the vocal cord palsy was documented by cross-sectional computed tomography. In conclusion, computed tomography is of great help in differentiating this syndrome from other diseases such as mediastinal mass or lymphadenopathy whenever hoarseness is complicated by pulmonary hypertension.

Significant coronary artery disease detected by amyl nitrite and systolic time intervals.

The relation between changes in left ventricular systolic time intervals with amyl nitrite (AN) inhalation and the severity of coronary artery disease (CAD) was evaluated in 77 patients who underwent catheterization because of chest pain. In 25 subjects with normal coronary angiograms (control group), AN inhalation increased the ejection time (ET), shortened the preejection period (PEP) and increased the ET/PEP markedly. In the 52 patients with CAD (CAD group), the ET/PEP changed insignificantly after AN. The difference between the 2 groups was significant (p less than 0.001). At cardiac catheterization, the increase of left ventricular dP/dt after AN in the control group was significantly larger than that in the CAD group. Although a positive correlation between changes in ET/PEP with AN and ejection fraction at rest was noted in patients with 1-vessel CAD, no such correlation was noted in those with multivessel CAD. This suggests that factors in addition to pump function, such as the degree of CAD, influence the effect of AN inhalation on systolic time intervals. When an increase of less than 30% in ET/PEP occurs with AN inhalation, the presence of significant CAD can be detected with a sensitivity of 92%, a specificity of 84% and the predictive value of 92%. The AN inhalation test is safe and simple, and thus could serve as a stress test for evaluating the presence and severity of significant CAD.

Measurement of point velocity in the canine coronary artery by laser Doppler velocimeter with optical fiber.

A laser Doppler velocimeter with an optical fiber was developed to investigate point blood velocity in the arteries and was applied to the measurement of blood velocity in the canine coronary artery. Fundamental experiments revealed that the accuracy of this method was satisfactory, since an excellent linear relation was found between the known blood velocity and the Doppler shift frequency (r = 0.998). The fiber tip (0.1 mm diam.) was inserted into the proximal portion of the left circumflex coronary artery and was traversed across the vascular lumen to measure the point velocity at each sampling point. Detailed velocity profiles were than reconstructed sequentially in three dimensional coordinates, i.e., velocity, diameter and time. In general the velocity waveform showed a diastolic dominant pattern which is characteristic of coronary arterial flow. One peak in early systole and two peaks in early and in late diastole were commonly observed in the velocity waveform near the center-line of the vessel. The velocity profiles were flat in the axial region and declined abruptly near the vessel wall. These results indicate that the laser Doppler velocimetry with an optimal fiber proved to be an accurate and feasible method of evaluating the point velocity of coronary artery flow.