Pancytopenia and colitis with Clostridium difficile in a rheumatoid arthritis patient taking methotrexate, antibiotics and non-steroidal anti-inflammatory drugs.

Methotrexate (MTX) is widely used despite its side-effects. We describe a rheumatoid arthritis (RA) patient taking low-dose MTX who developed severe pancytopenia and colitis with Clostridium difficile after the administration of antibiotics for acute pyelonephritis. Our case suggests that low-dose MTX may seriously interact with antibiotics and that these side-effects should always be considered when RA patients are treated with MTX and antibiotics.

[Infratentorial hemorrhage following supratentorial surgery].

Hemorrhage in regions remote from the site of initial intracranial operations is rare, but does occur. We report three cases of cerebellar hemorrhage that developed after supratentorial surgery, all of which had similar clinical findings and CT images. The first case was a 37-year-old man with a craniopharyngioma in the suprasellar lesion. Partial removal of the tumor was performed through frontal craniotomy and the translaminaterminals approach. A large quantity of cerebospinal fluid (CSF) was suctioned from the third ventricle during the operation, resulting in marked brain shrinkage. The second and third cases were 34- and 51-year-old women with unruptured right middle cerebral aneurysms. Clipping of the aneurysms through the pterional approach was performed in both cases. In the second case, CSF was suctioned in large quantity from the carotid and prechiasmal cistern at the operation, resulting in marked brain shrinkage. In the third case, however, only a small volume of CSF was suctioned from the carotid and prechiasmal cistern during the operation, and no marked brain shrinkage was observed. CT scan showed that the hematomas were located mainly in the subdural or the subarachnoid spaces over the cerebellar hemisphere and partially extending into the cerebellar cortex. The mechanism of cerebellar hemorrhage in these series of patients was thought to be multifactorial. The possible etiology for cerebellar hemorrhage in the three cases presented was examined, including the role of CSF suction during surgery and disturbance of venous circulation in the posterior fossa. Suction of the CSF may cause intracranial hypotension. Further reduction of intracranial pressure leads to an increased transluminal venous pressure. There was no episode of hypertension or disturbed blood coagulation during or after the operation. The preoperative angiogram also revealed no abnormality at the region of the posterior fossa. Neuroimaging of infratentorial hemorrhage after supratentorial craniotomy is obviously different from that of hypertensive cerebellar hemorrhage. From the shape or extension of the hemorrhage, the main vessels of hemorrhage are the superior vermian vein and their tributaries damaged by stretching and tearing of these vessels. These vessels are not demonstrable in the angiogram, therefore there is no evidence for this hypothesis and the etiology is still unclear. There is no doubt, however, that there was a disturbance of venous circulation in this complication. We would like to emphasize the possibility of this complication. Patients who show signs of difficulty in awaking from anesthesia or the development of new neurological deficits not attributed to direct operative procedure after supratentorial craniotomy must be evaluated early, with adequate imaging including the posterior fossa.

[A case of hearing loss caused by overdrainage of cerebrospinal fluid after ventriculo-peritoneal shunting procedure].

We describe a case of intracranial hypotension syndrome due to overdrainage of cerebrospinal fluid presented with hearing loss after ventriculoperitoneal shunting procedure. A 69-year-old man suffering from subarachnoid hemorrhage presented with an angiogram showing two aneurysms, one of the right internal carotid and one of the middle cerebral artery. Neck clipping was performed. One month later, he developed normal pressure hydrocephalus (NPH), which was treated by ventriculoperitoneal (NPH), which was treated by ventriculoperitoneal shunting procedure using low pressure Pudenz system. Trias of NPH were improved by insertion of shunt system. However, he complained of hearing loss which was worsened by upright position and improved by lying down. Such kinds of phenomenon were demonstrated by audiogram showing that the transitory decrease of hearing and electrocochleography showing the elongation of N1 latency at upright position. These data suggested that his hearing loss was caused by inner ear or auditory nerve lesion. After the shunt system was replaced into the antisiphon device, his hearing disturbance improved. Axial computed tomography of bone window at the level of orbitomeatal line demonstrated widely perilymphatic duct on both sides. This finding suggested that the fluctuation of intracranial pressure was easily transmitted into the cochlear through the widened perilymphatic duct, resulting in hearing disturbance.

Altered reactivity of human cerebral arteries after subarachnoid hemorrhage.

To investigate the effects of subarachnoid hemorrhage (SAH) on the responsiveness of human cerebral arteries to vasoactive substances, the authors measured the isometric tension generated in helical strips of basilar and middle cerebral arteries isolated from human cadavers. Contractions caused by KCl, prostaglandin F2 alpha, noradrenaline, and serotonin were reduced in arteries obtained from cadavers with aneurysmal SAH damage and compared to those obtained from cadavers with no indication of intracranial diseases. Endothelium-dependent relaxation elicited by substance P and bradykinin, and endothelium-independent relaxation induced by prostaglandin I2 and nitroglycerin were also markedly decreased in arteries affected by SAH. However, the reduction in relaxation response to prostaglandin I2 was significantly less than that to the other vasodilator agents. These results indicate that human cerebral artery functions are severely impaired after SAH and that poor responses to vasoactive agents may result primarily from dysfunction of smooth-muscle cells.

Human basilar and middle cerebral arteries exhibit endothelium-dependent responses to peptides.

We examined the activities of bradykinin, substance P, and vasopressin in isolated human cerebral arteries to better understand humoral control of cerebrovascular tone. Basilar and middle cerebral arteries were isolated from human cadavers during autopsy, and isometric tension was measured in helical strips of the arteries. Both bradykinin and substance P relaxed strips of both arteries precontracted with prostaglandin F2 alpha to similar extents. The relaxations induced by both peptides were abolished by removal of the vascular endothelium and were markedly reduced by pretreatment with NG-nitro-L-arginine, an inhibitor of endothelium-derived relaxing factor. Treatment with indomethacin, a cyclooxygenase inhibitor, did not attenuate the relaxations. These results indicate that the responses of human cerebral arteries to bradykinin and substance P are mediated by endothelium-derived relaxing factor. In contrast, vasopressin primarily produced endothelium-independent contractions in human cerebral arteries. Contractions of basilar arteries induced by vasopressin were much less than those of middle cerebral arteries. Two of eighteen basilar arteries, but none of the middle cerebral arteries, responded to vasopressin with endothelium-dependent relaxation. This suggests that the function of vasopressin receptors differs in basilar and middle cerebral arteries.

Fatal pneumomediastinum in dermatomyositis without creatine kinase elevation.

A 41-year-old woman developed fatal pneumomediastinum in the course of dermatomyositis. One characteristic feature of this patient was the relatively mild myositis with slight elevation of serum creatine kinase. In a literature review, some of the patients with dermatomyositis, but not polymyositis, with a very slight elevation of serum creatine kinase tended to develop spontaneous pneumomediastinum during corticosteroid therapy. Since pneumomediastinum is a highly fatal complication in patients with dermatomyositis, only slight elevation of creatine kinase could be a marker for poor prognosis. Thus, mild/minimal myositis in patients with dermatomyositis should be carefully observed irrespective of corticosteroid therapy.

[Surgery versus detachable balloon embolization of pulmonary arteriovenous fistula: clinical experience].

We experienced 4 pulmonary arteriovenous fistula cases 2 of which were treated surgically and 2 were subjected to detachable balloon embolization therapy. Favorable results were obtained in the detachable balloon embolization therapy. In treating pulmonary arteriovenous fistula, if the lesion is in the position where the catheter can be reached easily and is composed of a single afferent-efferent vessel unit, it would be advisable to perform the embolization therapy first, and then to apply an operative procedure preserving lung tissue as much as possible.

[Effect of short-term administration of medroxyprogesterone acetate on side reactions of combination chemotherapy with ADR, VDS and CDDP in primary lung cancer].

The effect of short-term (10 days) Medroxyprogesterone acetate (MPA) administration on side reactions of combination chemotherapy with ADR, VDS and CDDP for primary lung cancer was studied by comparisons of MPA administration group (20 cases) with non administration group (30 cases). 1) Frequency of vomiting, duration of nausea and body weight loss were significantly improved in MPA administration Group (p less than 0.01). 2) Leukocyte and neutrophil counts in MPA administration group especially 7-10 days after of chemotherapy were maintained higher than these of non administration group (p less than 0.05). 3) Major side effects including thromboembolism in MPA administration group had not been observed. These results indicated that short-term MPA administration was relatively safe and effective in combination chemotherapy including CDDP.

[Behçet's disease associated with multiple cerebral aneurysms and downhill esophageal varices caused by superior vena cava obstruction: a case report].

A 62-year-old woman who had suffered from Behçet disease since 1975 was admitted to Kawasaki Municipal Hospital because of severe headache and consciousness disturbance in July 1988. The emergency brain CT scan showed subarachnoid hemorrhage. Despite clipping the neck of the cerebral aneurysm, she died of cerebral herniation. Post-mortem examination revealed four aneurysms on the anterior part of the circle of Willis: 1) at the first bifurcation of the right middle cerebral artery 2) at the bifurcation of the left internal carotid artery 3) at the anterior communicating artery 4) at the left middle cerebral artery. The complete obstruction of the superior vena cava and downhill esophageal varices with no evidence of portal hypertension were also observed. This case had downhill esophageal varices induced by vena caval obstruction as a quite rare symptom of vasculo-Behçet's disease and also complicated with congenital multiple aneurysms of cerebral arteries.

[Clinical study on two cases of progressive systemic sclerosis with anti Wa antibody].

It is well known that patients with progressive systemic sclerosis (PSS), as well as other autoimmune disease, have various kinds of autoantibodies. We presented two PSS patients with anti Wa antibody, which had recently been reported as a new anti cytoplasmic antibody in only one case with PSS. Our first case, 49 years old female had clinical features of arthralgia, Raynaud's phenomenon, sclerodactyly, transient myalgia and sicca complex. Her laboratory findings showed hypergammaglobulinemia (1.9 g/dl), positive RAHA (1: 640) anti Wa antibody (1: 256), and anti SS-A antibody (1: 256). Second case, 64 years old female had also clinical features of Raynaud's phenomenon, sclerodactyly, dysphagia, dyspnea on exertion and dry mouth. Furthermore lung fibrosis and dysmobility of upper GI tract were observed. FANA (1: 20) was detected as nucleolar pattern, and the titer of anti Wa antibody was 1: 64. Clinical findings of myositis were not seen in both cases. This study suggested that anti Wa antibody might be one of the diagnostic marker on PSS.

[Clinical studies on septicemia and infective endocarditis encountered between 1985-1986].

Septicemia encountered at Kawasaki Municipal Hospital between 1985 and 1986 were studied clinically. Forty six patients had monomicrobial and 5 has polymicrobial infections, respectively. Out of these 46 patients with septicemia, 17 were due to Escherichia coli, 7 were due to Klebsiella pneumoniae and 4 were due to Staphylococcus aureus. Ten patients had hepatobiliary, 7 had hematological, 7 had malignant diseases as underlying diseases, respectively. Out of 10 patients complicated with septic shock, 7 died. Twenty three patients were community acquired infections. The age of most of the patients were over 50. The mortality rate of more than 65-year-old patients were higher than that of other patients. Our of 5 patients with septicemia due to polymicrobial infection, only 1 patient with erythroleukemia died. Fifty patients were treated mainly with beta-lactam antibiotics such as piperacillin or cefmetazole alone or in combination with aminoglycosides and so on. Three patients with infective endocarditis were encountered during this period. Two were due to alpha-streptococcus and 1 was due to Enterococcus. A 41-year-old patient with mitral valve insufficiency and metastatic gastric carcinoma to the bone marrow were complicated with disseminated intravascular coagulation. This patient, however, was successfully treated with a daily dose of 24 mega units of benzylpenicillin, and was given gabexate mesilate, concomitantly.

[Clinical study on SM-4300 in the field of internal medicine].

A new human gamma-globulin for intravenous use, SM-4300, was administered to 13 patients with infectious diseases. Five grams of SM-4300 was drip infused to each patient whose infection was not controlled by previous administered antibiotics. All of 13 patients had primary diseases besides infections. Thirteen patients were composed of 4 with pyelonephritis, 2 with pneumonia, 1 with bronchopneumonia, 1 with bronchitis, 1 with pyothorax, 2 with sepsis and 2 with cholecystitis. The results obtained were good in 3 cases, fair in 2 cases and poor in 7 cases. The results of a patient was not determined. No side effect was found including in laboratory findings.