Type III Kounis Syndrome Caused by Iodine Contrast Media After Improvement of Allergic Symptoms.

Kounis syndrome is an acute coronary syndrome (ACS) caused by an allergic reaction that almost always occurs immediately and simultaneously with allergic symptoms. We present a case of Kounis syndrome type III that developed after complete resolution of contrast-induced anaphylaxis in a 60-year-old man with a coronary stent placed in the proximal left anterior descending (LAD) artery branch for ischemic heart disease. Contrast-enhanced computed tomography revealed anaphylactic shock. Symptoms quickly improved with intramuscular adrenaline injection; however, chest pain appeared after approximately 30 min. ECG revealed ST-wave elevation in the precordial leads. Coronary angiography revealed acute stent thrombosis with total occlusion of the proximal LAD, and percutaneous coronary angioplasty was performed. We diagnosed Kounis syndrome based on the allergic symptoms and ACS. Because some cases of Kounis syndrome develop after anaphylactic symptoms have resolved, it is advisable to follow-up patients with allergic symptoms and pay attention to chest symptoms and ECG changes, especially when they have a history of noted or treated coronary artery disease.

Press-through package mis-swallowing: Usefulness of computed tomography.

Case: An 88-year-old female with Alzheimer's-type dementia who mis-swallowed a press-through package visited our emergency department. Outcome: Plain radiography detected no foreign bodies, whereas plain computed tomography showed an elliptical body with a high density in the lower esophagus. The press-through package containing a tablet in the esophagogastric junction was successfully removed without severe complications using the endoscopic protector hood. In cases of press-through package mis-swallowing, it is important for emergency physicians to make an early and correct diagnosis of the location of the package, which shows high radiolucency. Based on the results of this case, we hypothesize that carrying out early computed tomography examinations is useful for identifying swallowed press-through packages. Our retrospective investigation showed that computed tomography has a sensitivity of 100% for detecting press-through packages. Conclusion: We experienced a case of press-through package mis-swallowing diagnosed on computed tomography. We recommend performing computed tomography examinations, especially in patients with an uncertain history and unclear symptoms.

Depletion of apoptosis signal-regulating kinase 1 prevents bile duct ligation-induced necroinflammation and subsequent peribiliary fibrosis.

Apoptosis signal-regulating kinase 1 (ASK1), also known as mitogen-activated protein kinase kinase kinase (MAP3K), is ubiquitously expressed and situated in an important upstream position of many signal transduction pathways. ASK1 plays a pivotal role in stressor-induced cell survival and inflammatory reactions. To ascertain the regulatory functions of ASK1 in bile duct ligation (BDL)-induced liver injury, we examined the net effects of ASK1 depletion on hepatic necroinflammation and/or fibrosis. We subjected C57BL/6 wild-type (WT) or ASK1-deficient (ASK1(-/-)) mice to sham or BDL surgery for 14 days. In day 3 BDL animals, ASK1(-/-) mice had significantly fewer bile infarcts along with more reduced interlobular or portal inflammatory infiltrate of various immune cells, including neutrophils, compared with WT mice in which ASK1 expression was markedly activated. Morphologically apoptotic hepatocytes or cholangiocytes were negligible in both the sham and BDL animals. In contrast, ASK1(-/-) mice had significantly less proliferating activity of not only hepatocytes but also large cholangiocytes than WT mice. Day 14 BDL ASK1(-/-) mice manifested potential antifibrogenic aspects of ASK1 deficiency, characterized by significantly fewer activated peribiliary fibrogenic cells and peribiliary fibrosis. These observations indicate that ASK1-mediated hepatic necroinflammation and proliferation, but not apoptosis, are closely linked to liver fibrosis and fibrogenesis. A specific ASK1 pathway blocker or inhibitor might offer a therapeutic strategy against human cholestatic diseases.

Progression of Tokyo Guidelines and Japanese Guidelines for management of acute cholangitis and cholecystitis.

The Japanese Guidelines for management of acute cholangitis and cholecystitis were published in 2005 as the first practical guidelines presenting diagnostic and severity assessment criteria for these diseases. After the Japanese version, the Tokyo Guidelines (TG07) were reported in 2007 as the first international practical guidelines. There were some differences between the two guidelines, and some weak points in TG07 were pointed out, such as low sensitivity for diagnosis and the presence of divergence between severity assessment and clinical judgment for acute cholangitis. Therefore, revisions were started to not only make them up to date but also concurrent with the same diagnostic and severity assessment criteria. The Revision Committee for the revision of TG07 (TGRC) performed validation studies of TG07 and new diagnostic and severity assessment criteria of acute cholangitis and cholecystitis. These were retrospective multi-institutional studies that collected cases of acute cholangitis, cholecystitis, and non-inflammatory biliary disease. TGRC held 35 meetings as well as international email exchanges with co-authors abroad and held three International Meetings. Through these efforts, TG13 improved the diagnostic sensitivity for acute cholangitis and cholecystitis, and presented criteria with extremely low false positive rates. Furthermore, severity assessment criteria adapted for clinical use, flowcharts, and many new diagnostic and therapeutic modalities were presented. The world's first management bundles of acute cholangitis and cholecystitis were also presented. The revised Japanese version was published with the same content as TG13. An electronic application of TG13 that can help to diagnose and assess the severity of these diseases using the criteria of TG13 was made for free download.

Papillary carcinoma arising in thyroglossal duct cyst in the lateral neck.

The patient presented here, a 74-year-old female, had a 3-year history of a gradually enlarging painless nodule in the right submental lateral region of the neck. A neck CT scan showed a well-demarcated cystic lesion, measuring 25mm in diameter, but without any definite evidence of neoplastic foci in the lymph nodes, thyroid gland, or lung. Clinicians first interpreted it as branchial cleft cyst, and a cystectomy was performed. Gross examination revealed a unilocular cystic lesion filled with yellowish clear fluids, containing a markedly thinned fibrous wall with smooth inner surface, partly coexisting with tiny solid and papillary-like components. On microscopic examination, the cystic tumor was lined by mono-layered ciliated columnar or metaplastic stratified squamous epithelium with underlying ectopic thyroid follicles or lymphocytic infiltrate, reminiscent of thyroglossal duct cyst (TDC), partly adjacent to the compressed lymph node tissue. Its solid parts were composed of a proliferation of atypical cuboidal to columnar epithelial cells with occasional nuclear grooves or intranuclear inclusions, arranged in a papillary growth pattern with supporting delicate fibrovascular cores. Immunohistochemically, these atypical cells were positive for thyroid transcription factor 1, thyroglobulin, and cytokeratin 19. Therefore, we finally made a diagnosis of papillary carcinoma (PC) arising in TDC in the lateral neck. Although metastatic thyroid PC of cervical lymph node was an important differential diagnosis owing to various overlapping clinicopathological features, coexistent benign lining epithelium or thyroid follicles, a histological hallmark of TDC, were present in the current case.

Pulmonary Paragonimus westermani with false-positive fluorodeoxyglucose positron emission tomography mimicking primary lung cancer.

We report the case of a 66-year-old woman with pulmonary Paragoniumus westermani showing false-positive fluorodeoxyglucose positron emission tomograpy (FDG-PET). Based on chest computed tomography and FDG-PET findings, we could not rule out the possibility of primary lung cancer. She underwent right middle and lower lobectomies as a primary lung cancer. As a possibility in the differential diagnosis of a pulmonary nodule with FDG-PET positive findings, paragonimiasis should be considered, although it is rarely seen.