[A 56-year-old woman with parkinsonism and dementia with the age of onset at 41 years]

We report a 56-year-old woman with parkinsonism and dementia who died of respiratory failure. The patient was well until the age of 41 when she noted insidious onset of difficulty in moving around. Soon after, she noted tremor in both her hands and gait disturbance. She received stereotaxic right thalamotomy when she was 46-year-old; after thalamotomy, improvement was noted in her tremor, rigidity, and in gait. However, a few months later, she started to experience motor fluctuations with worsening of her symptoms in the afternoon. This worsening was temporarily relieved by increasing her levodopa/benserazide dose. She started to show visual hallucination and agitation when she was 54-year-old. Her symptoms had progressively become worse with marked motor fluctuations and she was admitted to our hospital when she was 56-year-old. On admission, she was alert and general physical examination was unremarkable. Neurologic examination revealed that she was disoriented to time and place; memory was markedly disturbed and calculation was poor. Hasegawa dementia scale was 7/30. Higher cerebral functions appeared intact. She showed masked face, small voice, and some dysphagia. Other cranial nerves were intact including ocular movements. She was unable to walk by herself; when supported she walked in small steps with marked disturbance in the righting reflex. Mixed rigidity and Gegenhalten was noted in her four limbs and in the neck. Tremor was absent. She showed marked akinesia.(ABSTRACT TRUNCATED AT 250 WORDS)

[A case of primary cryptococcosis of the lung]

A 37-year-old man was pointed out having an abnormal shadow in the right lung field at a medical checkup in July 1992. There was 5-year life history of rearing about 60 macaws since 10 years before. Upon operation a tumor 1.5 cm in diameter was palpated in the right S6. Intraoperative frozen section diagnosis revealed no malignancy. Partial excision was performed. The excised specimen showed a 1.5 x 1.4 x 1.0 cm, well-defined and yellowish white tumor. Histologically it was granuloma with a thin fibrous capsula, and most of the granuloma necrotized involving cryptococcus formans. Postoperative serum cryptococcus antigen and antibody titers were negative. There has been no sign of recurrence, as of 8 months after the operation. No adjuvant chemotherapy has been needed.

Doxorubicin-heparin complex: reduction of cardiotoxicity of doxorubicin

We have compared the antitumor activity and cardiotoxicity of free doxorubicin (Dox) and doxorubicin-heparin complex in vivo and in vitro. Dox and Dox-heparin complex equally inhibited the DNA synthesis of leukemic cells and showed a similar anticancer activity against tumor-bearing mice. Acute toxicity of Dox at the dose of 20 mg/kg or 30 mg/kg was significantly more profound than that of the Dox-heparin complex, which was demonstrated by survival rate (P < 0.01). Chronic toxicities of Dox and the Dox-heparin complex were compared by giving the respective reagent (2 mg/kg) weekly for 20 weeks. The weight gains of the mice given Dox-heparin complex were greater than those of the mice given Dox alone (P < 0.01). The pathological damage to the cardiac tissue in mice treated with Dox-heparin complex was significantly less severe than that of mice treated with Dox. Thus, the present study indicates that complexing with heparin diminished the acute and chronic toxicity of Dox without reducing its antitumor activity in mice, and suggests a possible clinical application of Dox-heparin complex in humans.

[The clinical usefulness of botulinum toxin type A for spasmodic torticollis and facial spasm]

We studied the clinical effectiveness of botulinum toxin type A for spasmodic torticollis and that for facial spasm by multicenter, non-blinded study. The freeze-dried crystalline botulinum toxin type A (AGN 191622; Allergan Inc., Irvine, CA) was injected into the hyperactive muscles and the clinical course was followed for 22 weeks. Repeated injections were done, if necessary, with an interval of 4 weeks. The toxin was highly effective in both disorders. In spasmodic torticollis, clinical severity improved in 38 (63.3%) and the global improvement was seen in 39 (65.0%) out of 60 patients. Subjective improvement was seen in 56 (93.3%). In facial spasm, 52 (92.9%) out of 56 patients improved after the treatment. Unfavorable reactions, mainly consisting of neck muscle weakness and dysphagia in torticollis and facial weakness in facial spasm, were mostly due to the excessive action of the toxin. They were usually mild and transient. No patients discontinued the trial because of side effects. Botulinum toxin injection is a very useful and safe method for the symptomatic treatment of spasmodic torticollis and facial spasm.

[A 86-year-old woman with dementia, gait and speech disturbance, and right hemiparesis]

We report a 86-year-old woman who developed dementia, gait disturbance, speech disturbance, and right hemiparesis. The patient was well until March of 1979 when upon wakening up on one morning she noted slurring of her speech and weakness in her left upper and lower extremities. These symptoms cleared up during the next several months, however, she noted weakness in her left leg again in May 1985. In 1988, her posture became stooped and she walked in small steps. In 1990, she developed memory disturbance and difficulty in naming. In March 1993, she developed weakness in her right hand; she was treated with aspirin and amantadine HCl, however, she deteriorated during the next two week period, and was admitted to our hospital on March 27, 1993. On admission, she appeared alert, however, she could not answer verbally to questions; she could only utter unintelligible sounds. Apparently she was markedly demented. Her blood pressure was 170/98 mmHg, and general physical examination was unremarkable. Cranial nerves were grossly normal except for marked non-fluency in her word expression. She could not stand or walk, and apparently her right upper and lower extremities were paralyzed with some contracture. Deep reflexes were normally active without asymmetry. Chaddock sign was positive bilaterally. Sensory examination was difficult. Pertinent laboratory examination included WBC 13,000/microliters, BUN 152mg/dl, creatinine 3.75mg/dl, CRP 20.1mg/dl; a chest X-ray film revealed pneumonic shadow in the upper and the middle right lung fields. Cranial CT scan revealed multiple lacunar infarctions in both basal ganglia and cerebral white matters; periventricular lucency was also noted. She was treated with antibiotics and intravenous fluid. Acid-fast bacilli were recovered from sputum, and she was transferred to another hospital for the treatment of pulmonary tuberculosis. After its treatment she returned to our hospital on July 8, 1993, when her condition was complicated with aspiration pneumonia. On admission, she was semicomatose, and no intelligible words were heard. Right facial paresis of the central type was noted. She was unable to stand or walk, and her right upper and lower extremities were paretic. Deep reflexes were increased with extensor toe sign on the right. She was treated with chemotherapy and intravenous fluid, however, her clinical course was complicated with respiratory as well as urinary tract infections. She developed cardiac as well as renal failure and expired on September 25, 1993.(ABSTRACT TRUNCATED AT 400 WORDS)

[Effect of body weight reduction on blood pressure and biochemical data]

The purpose of this study was to investigate the relation between body weight reduction and some complications associated with obesity. The subjects were 248 middle-aged obese persons (male 37, female 209) who participated in a weight reduction program at the Aichi Prefectural Center of Health Care from 1983 to 1990. The subjects had no severe complication, and the obesity indexes of all of them were over 120%. The program was held monthly for five months and consisted of diet (1500 kcal/day) and exercise (10000 walk steps/day). After the program, mean obesity index decreased by about 9%, and mean body weight reduction was about 5kg. Blood pressure, total cholesterol, triglyceride and GPT were significantly decreased, and HDL cholesterol was slightly increased. For each item the percentage of persons with abnormal values reduced by about 5 to 20%. From the relationship between degree of decrease of obesity and changes of the values of each item, it was estimated that some complications of obesity require greater than 5 to 10% decrease in obesity index to be affected. The value of each examination item before the program and the degree of decrease of obesity index had an effect on changes of the values, but obesity index before the program and age had little effect.

Neoplastic alterations in subcellular distribution of type 1 alpha protein phosphatase in rat ascites hepatoma cells

Neoplastic alterations of type 1 alpha protein phosphatase (PP1 alpha) have been studied in rat ascites hepatoma cells, using regenerating liver after partial hepatectomy and normal rat liver as controls. In the particulate fraction of hepatomas, potential PP1 activity and the amount of PP1 alpha were remarkably increased compared with either regenerating or normal livers. In the nuclear fraction, PP1 activity and the amount of PP1 alpha were increased in hepatoma compared with the controls. The nuclear PP1 activity in hepatomas was activated by treatment with CO2+/trypsin, whereas that of normal or regenerating liver was not activated. These characteristic alterations of PP1 alpha in its amount and subcellular distribution may be implicated in malignant phenotype(s) such as uncontrolled cell growth.

Decrease in cerebellin and corticotropin-releasing hormone in the cerebellum of olivopontocerebellar atrophy and Shy-Drager syndrome

Four neuropeptides; cerebellin, corticotropin-releasing hormone (CRH), neuropeptide Y and somatostatin were studied by radioimmunoassay in the postmortem human brains obtained from three patients with olivopontocerebellar atrophy (OPCA) and one with Shy-Drager syndrome. Significant decreases in cerebellin and CRH concentrations were found in the cerebellar hemisphere of these diseases compared with controls. These findings suggest important pathophysiological roles of cerebellin and CRH in these cerebellar diseases. Such significant decreases were not found in neuropeptide Y and somatostatin.

Loss of heterozygosity in chromosomes 1, 5, 7 and 13 in mouse hepatoma detected by systematic genome-wide scanning using RLGS genetic map

We have developed an RLGS-based scanning system to detect DNA alteration in tumor tissues, using 575 mapped spots/loci in a single gel. This system is very powerful for screening and identifying not only loss of heterozygosity (LOH) but also DNA methylation change. In this study, we applied this system to search for the LOH of hepatoma from an interspecific F1 hybrid between Mus spretus and C57BL/6 with SV40 early T antigen transgene connected to a mouse major urinary protein enhancer/promoter. Comparing the RLGS profiles of each tumor to that of the normal tissue showed significant LOH in chromosomes 1, 5, 7 and 13.

Dystrophin-associated protein A0 is a homologue of the Torpedo 87K protein

We raised a monoclonal antibody, MA0, which reacts with A0, a 94-kDa rabbit skeletal muscle dystrophin-associated protein (DAP) bound to the syntrophin-binding domain of dystrophin. The antibody also reacted with the 62-kDa DAP which was moved to the locus close to beta-syntrophins by 2-dimensional PAGE, but the DAP did not coincide with any known beta-syntrophins. We have cloned a fragment of cDNA which codes the protein reacting with MA0 from a neonatal rabbit heart cDNA library. Based on the coincidence of cDNA sequences and the similarity in molecular mass, we concluded that the proteins reacting with MA0 are rabbit homologues of the Torpedo 87K protein.

[A 57-year-old woman with gait disturbance, headache, character change, convulsion, and coma]

We report a 57-year-old woman with progressive gait disturbance, headache, character change, convulsion and coma. She was well until 55 years of age, when she noted an onset of unsteady gait. At times she experienced transient weakness in her right hand, which was followed some difficulty in articulation. She was admitted to our service for the work up on April 6, 1992. Neurologic examination at that time revealed an alert Japanese lady in no acute distress. She was oriented to all spheres, however, she was somewhat bradyphrenic and had some disturbance in recent memory. Higher cerebral functions appeared intact. The visual acuity and visual fields were normal as were the optic fundi. Pupils were round and isocoric reacting promptly to light. Ocular movement was full, however, horizontal nystagmus was noted upon right lateral gaze. The sensation of the face was intact. She showed right facial paresis of the central type. Hearing was intact. She showed slurred speech and some difficulty in swallowing. The tongue was deviated to the right. Her gait was wide based and unsteady; tandem gait was difficult, however, walking on toes and on heels were performed well. No cerebellar ataxia was noted, but she showed some clumsiness in her right hand. Deep reflexes were symmetric and normally reactive; plantar response was extensor bilaterally. Sensation was intact; no meningeal sign was elicited. Routine laboratory work up was unremarkable; the CSF was under a borderline pressure (180 mmH2O) and contained 39 mg/dl of protein and 59 mg/dl of sugar. Cranial CT scan revealed diffuse low density areas involving bilateral cerebral white matter as well as the brain stem; MRI revealed high signal intensity lesions in those areas; gadolinium enhancement was negative; cortical sulci were effaced and the anterior part of the left lateral ventricle was compressed without deviation of the midline structure. The patient was treated with steroid pulse therapy without effect. She was discharged for out patient follow up, however, she developed a convulsion which was followed by loss of consciousness, and was admitted again to our service. She had never gained consciousness after this episode, and remained in the state of akinetic mutism. Follow-up CT and MRI did not show much change, although the area of high signal density lesions slightly enlarged on June 1, 1993. Her clinical course was complicated by drug induced bone marrow suppression and nephrotic syndrome. She expired on September 8, 1993 after developing sudden drop of blood pressure and bradycardia.(ABSTRACT TRUNCATED AT 400 WORDS)

[A 51-year-old man with early onset parkinsonism]

We report of 51-year-old man with early onset parkinsonism. The patient was well until 38 years of age, when he noted a difficulty in the use of his right leg; this difficulty improved after he received a medicine from his physician. He did not take medicine regularly, and he noted difficulty in standing up from a chair and in rolling over at age 40. Tremor was not a feature, but he noted slowness in his movements at age 42; at age 49, he noted diurnal fluctuation in his symptoms and at times he experienced hallucination. He was admitted to our hospital in September of 1992 for the first time when he was 50-year-old. At that time, neurologic examination revealed an alert and somewhat bradyphrenic man; Hasegawa dementia rating scale was 20/30. Cranial nerves were intact except for masked face and small voice. He showed stooped posture and small step gait cogwheel rigidity was noted in the four limbs more on the left; tremor was absent. Deep reflexes were within normal range and the sensation was intact. As he showed diurnal fluctuation in his symptoms, his medication was switched to levodopa 3,000 mg/day without a peripheral decarboxylase inhibitor. He was discharged for out patient follow up. But he did not take drugs regularly, and his neurologic condition deteriorated; he was admitted to another hospital. Neurologic examination at that time was essentially similar to that of his first admission to our hospital, except that he showed more severe rigidity and akinesia; again tremor was not detected. His cranial CT scan showed a mild ventricular dilatation without cortical or brain stem atrophy. During his hospital stay, he developed episodes of oculogyric crisis during peak dose of levodopa, and orthostatic hypotension. He developed pneumonia and expired on October 28, 1993. He was discussed in a neurological CPC, and the chief discussion arrived at the conclusion that the patient had early onset Parkinson's disease of Lewy body type. As differential diagnoses, early onset parkinsonism without Lewy body, pure form of diffuse Lewy body disease, pallidoluysian atrophy, and other conditions were considered; however, all of those possibilities were excluded. Early onset parkinsonism without Lewy body would have much earlier onset than this patient, and diffuse Lewy body disease would show more profound dementia 13 years after the onset. Pallidoluysian atrophy would be complicated with some dystonic features. Post-mortem examination showed marked discoloration and degeneration of the substantia nigra. The degeneration was most prominent in the ventrolateral tier of the substantia nigra.(ABSTRACT TRUNCATED AT 400 WORDS)

[A characteristic blink response observed in a patient with Lance-Adams syndrome--somatosensory-evoked blink response]

We report a patient with Lance-Adams syndrome, in whom a characteristic blinking response was observed. In this patient, the reflex blinking was elicited by electrical stimulations applied not only to the supraorbital nerve but also to peripheral nerves of both upper and lower extremities. The EMG discharges responsible for the blinking response were found to consist of some components. The pathophysiological mechanism underlying the characteristic blinking response was discussed. It is speculated that increased excitabilities of the brainstem reticular formation may play a role in generating this type of blinking response, namely the somatosensory-evoked blink response.

Peripheral expansion of V delta 1-J delta 1/J delta 2+ gamma delta T cells and large granular lymphocytes in a patient with Wiskott-Aldrich syndrome

A 7 month old Japanese boy was diagnosed to have Wiskott-Aldrich syndrome (WAS) because of eczema, thrombocytopenia, progressive immune defect and CD43 (sialophorin) abnormality. He had developed repeated infections since 16 months of age. Gamma delta T cell-receptor positive T cells in the peripheral blood were gradually increased from 3.1% (7 months of age) to 5.6% (12 months), 19.6% (18 months) and 56.7% (25 months). The phenotypes of expanded gamma delta T cells were delta TCS1-positive (V delta 1-J delta 1/J delta 2) and CD8 dim-positive. The proportion of increased granular lymphocytes correlated well with that of gamma delta T cells. The significance of peripheral expansion of gamma delta T cells and granular lymphocytes in WAS is discussed.

Significance of urinalysis for subsequent kidney and urinary tract disorders in mass screening of adults

To evaluate dipstick urinalysis as a predictor of subsequent kidney and urinary tract disorders in apparently healthy adults, we designed a cross-sectional, prospective, and retrospective study within a cohort. The severity of proteinuria was significantly (p < 0.01) associated with the amount of pathological casts, whereas hematuria without proteinuria was not. The frequency of subsequent serum creatinine increase (0.3 mg/dl/5 years or more) was significantly enhanced (from 0.4% to 7.3% along with the severity of proteinuria, whereas it was not related to the severity of hematuria. Patients who subsequently developed renal failure and glomerulonephritis exhibited hematuria (11.1-32.1%) less frequent than proteinuria (62.3-83.3%). Even those with renal tumors or stones showed infrequent (14.3-27.9%) hematuria. Thus, urine protein and occult blood have different implications in mass screening.

Role of mitochondria in the etiology and pathogenesis of Parkinson's disease

We discuss the etiology and pathogenesis of Parkinson's disease (PD). Our group and others have found a decrease in complex I of the mitochondrial electron transfer complex in the substantia nigra of patients with PD; in addition, we reported loss of the alpha-ketoglutarate dehydrogenase complex (KGDHC) in the substantia nigra. Dual loss of complex I and the KGDHC will deleteriously affect the electron transport and ATP synthesis; we believe that energy crisis is the most important mechanism of nigral cell death in PD. Oxidative stress has also been implicated as an important contributor to nigral cell death in PD, but we believe that oxidative stress is a secondary phenomenon to respiratory failure, because respiratory failure will increase oxygen free-radical formation and consume glutathione. The primary cause of mitochondrial respiratory failure has not been elucidated yet, but additive effect of environmental neurotoxins in genetically predisposed persons appears to be the most likely possibility.

A case of 5-fluorouracil cardiotoxicity simulating acute myocardial infarction

5-Fluorouracil (5-FU) is widely used in the treatment of various solid tumors. However, 5-FU cardiotoxicity is being reported with increasing frequency. The main symptom of cardiotoxicity is chest pain at rest with ischemic electrocardiographic changes. Up until now, the underlying mechanism has been suspected to be coronary artery spasm. However, this chest pain associated with 5-FU has several characteristics that are incompatible with coronary artery spasm; eg, inefficacy of calcium-channel blocker and a slow increase in cardiac enzyme levels. We experienced a case of 5-FU-induced cardiotoxicity which showed clinical findings consistent with acute myocardial infarction. Based on the clinical findings, coronary angiography, and left ventricular angiography in a prolonged attack, we concluded that the cardiotoxicity in this case was not due to ischemia caused by coronary artery spasm.

Therapeutic effect of CDDP and VP-16 against human bladder cancers

In order to evaluate the anticancer effect of combination chemotherapy (CDDP and etoposide) against human bladder cancer xenografts transplanted in nude mice, we tried an experimental chemotherapy. The tumor was aseptically cut and subcutaneously transplanted into the backs of the nude mice. When the weight of each tumor reached 300 mg, CDDP (day 1; 4 mg/kg) and etoposide (day 1-5; 2 mg/kg) were given intraperitoneally as single agent or in combination and repeated every 3 weeks. The estimated weight (mg) was obtained by (larger diam. x smaller diam.2) x 1/2. A continuous significant effect was observed in CDDP combined with etoposide against bladder tumor. Therefore, these results suggest that the combination chemotherapy using CDDP with etoposide is an efficacious treatment against human bladder cancer.

[A 21-year-old man with distal dominant progressive muscle atrophy]

We report a 21-year-old man with distal dominant progressive muscle atrophy. The patient was apparently well until 17 years of age when he noted a decrease in exercise tolerance. One year later, he noted difficulty in arising his heels when the walked. He was admitted to our service for the work up in June 10, 1992. On admission, the patient was rather slender in the body build up; otherwise general physical examination was unremarkable. Upon neurologic examination, mental status and higher cerebral functions were normal. In the cranial nerves, the sternocleidomastoid muscles were atrophic bilaterally; other cranial nerves appeared intact. His gait was unstable and he showed steppage gait; walking on toes and heels were impossible. Distal dominant muscle atrophy was noted in both upper and lower extremities. Muscle strength in the deltoid, biceps brachii and triceps brachii was normal. In the lower extremities, both tibialis anterior and triceps surae muscles were weak (3/5). The iliopsoas and quadriceps femoris muscles were normal, however, the adductor muscles of the thigh showed marked weakness (2/5). Myotonia was absent. Deep reflexes were decreased; sensation was intact. Routine blood tests were unremarkable; CK was 96 IU/l, lactate 6.9 mg/dl, and pyruvate 0.61 mg/dl. After an ischemic forearm exercise test, blood lactate level rose to 22.5mg/dl (base line 11.2), and blood ammonia to 88.3 micrograms/dl (base line 71.2). EMG showed myogenic changes and myotonic discharges. A diagnostic biopsy was performed. The patient was discussed in a neurologic CPC, and the chief discussant arrived at the conclusion that the patient had type III glycogen storage disease. The differential diagnosis included rimmed vacuole type myopathy, Miyoshi type distal muscular dystrophy, Welander type muscular dystrophy, adult type acid-maltase deficiency, and lysosomal glycogen storage disease with normal acid maltase. However, characteristic clinical presentation of initial weakness in the triceps surae muscle associated with atrophy of the sternocleidomastoid muscle confirmed best of the clinical characteristics of type III glycogen storage disease; the only finding which did not fit with its diagnosis was elevation of the blood lactate level after the ischemic exercise test. The muscle biopsy specimen showed marked vacuole formation; approximately 20 to 30% of the vacuoles were rimmed vacuoles, however, the majority was not rimmed. PAS staining on an epon-embedded specimen revealed marked accumulation of PAS-positive materials in those vacuoles as well as in the interfascular space. The non-rimmed vacuoles were not positively stained in the acid-phosphatase staining, which exclude the diagnosis of acid maltase deficiency. No mitochondrial abnormalities were found.(ABSTRACT TRUNCATED AT 400 WORDS)

[Lifestyles and renal damage--association of smoking, drinking and physical activity with subsequent proteinuria]

To examine the role of lifestyles in the subsequent development of renal damage, the association of smoking, drinking and physical activity with subsequent proteinuria was investigated utilizing a longitudinal study. The subjects were 7,701 males aged 20-84 years, who participated in health examinations at Aichi Prefectural Center of Health Care, Nagoya, Japan, both in 1989-1990 and 1992-1993, and who showed no proteinuria at the first examination. Lifestyles at the first examination were compared between 140 men with, and 7,561 men without, newly developed proteinuria at the second examination. Age-adjusted odds ratios (ORs) of lifestyle factors for proteinuria were computed, and further the ORs were adjusted for age, systolic blood pressure, fasting plasma glucose level and other covariates obtained using multiple logistic regression analysis. Major significant findings which emerged from the present study were as follows. (a) The greater the consumption of alcohol per day, the higher the risk of subsequent proteinuria (trend p = 0.003). Heavy drinkers who consumed more than 58 g of alcohol per day experienced an increased risk (OR relative to non-drinker: 2.52). (b) Those who exercised less than once a week, and those who avoided walking even a short distance were at an increased risk (OR: 1.46, 1.55, respectively). Heavy drinking and low physical activity were found to be significantly associated with an increased risk of subsequent proteinuria even after adjusting for the covariates. An increasing risk of subsequent proteinuria with number of cigarette smoked per day was observed by univariate and multivariate analysis but without statistical significance.(ABSTRACT TRUNCATED AT 250 WORDS)

[A case of human growth hormone (h-GH)-producing adenocarcinoma of the lung]

The authors reported a case of a 56-year-old man with lung cancer which secreted human growth hormone (hGH). On admission, he had clubbed fingers and gonalgia without complaining cough or sputum. Serological examination revealed a high level of hGH which was 22.7 ng/ml (normal < 1.46). Right upper lobectomy was performed in February, 1994. It returned to the normal level after resection of the tumor. Gonalgia was improved but he still had clubbed fingers after operation. Histological examination of the tumor shows poorly differentiated adenocarcinoma with no evidence of lymph node metastasis. Immunohistochemical study showed that a group of the tumor cells demonstrated a specific reaction for anti-hGH antibody.

[A 65-year-old woman with dysarthria, dysphagia, weakness, and gait disturbance]

We report a 65-year-old woman with progressive dysarthria, dysphagia, weakness, and gait disturbance. The patient was well until 59 years of age (January of 1986) when she noted bilateral ptosis. One year later, she noted a gradual onset of difficulty in speech (articulation). Her speech slowly deteriorated and she noted weakness in chewing power and difficulty in swallowing in addition. In October 1987, she developed emotional incontinence. In January of 1988, she started to drag her left foot. She was admitted to our hospital on June 13 of 1988. On admission, she was alert and general physical examination was unremarkable. Neurologic examination revealed no dementia; her higher cerebral functions appeared intact. Ptosis was present bilaterally more on the right. She showed difficulty in opening her eyes on command; no contraction of the frontal muscles was seen upon attempted eye opening. There was a moderate limitation in the vertical gaze. Forced laughing and crying were seen. Facial muscles were moderately weak without apparent atrophy. The movement of the soft palate was very weak, and swallowing disturbance was more prominent for liquid staff. The tongue appeared somewhat small, however, no fasciculation was noted. Her step was small and the posture was stooped. Retropulsion was present, however, Romberg's sign was absent. No muscle atrophy was apparent, however, diffuse mile to moderate muscle weakness was noted in all four limbs. Cerebellar sign was absent. Deep tendon reflexes were exaggerated bilaterally, and Babinski sign was present on the left side. Sensation was intact. Routine blood tests were unremarkable as was a cranial CT scan. Her ptosis did not improve after 10 mg of edrophonium injection. CSF was also normal. She was transferred to another hospital but her neurological disabilities further progressed. In 1989, she was totally unable to move her limbs; she could only move her eyes; still consciousness was clear without dementia. She developed respiratory difficulty and expired on July 25, 1992. She was discussed in a neurological CPC, and the opinions were divided into ALS and primary lateral sclerosis (PLS). The chief discussant arrived at the conclusion that the patient might have had the pyramidal form of ALS. Postmorten examination revealed marked myelin pallor in the anterior as well as lateral corticospinal tracts. Pyramidal tract degeneration was prominent starting at the level of the cerebral peduncle and was continued to be seen until the level of lumbar cord. The number of anterior horn cells showed only slight decrease in the cervical level, however, it was normal in the lumbar cord.(ABSTRACT TRUNCATED AT 400 WORDS)