First report of hepatobiliary Mycobacterium avium infection developing obstructive jaundice in a patient with neutralizing anti-interferon-gamma autoantibodies

This study describes a patient who experienced hepatobiliary Mycobacterium avium infection associated with neutralizing anti–interferon gamma (IFN-γ) autoantibodies during treatment for disseminated M. avium disease. Hepatobiliary M. avium infection should be considered in jaundiced patients with neutralizing anti–IFN-γ autoantibodies, including those receiving antimycobacterial therapy for disseminated M. avium disease.

Serum lipid levels are positively associated with non-erosive reflux disease, but not with functional heartburn

BACKGROUND

Metabolic syndrome and obesity are known risk factors for gastro-esophageal reflux disease (GERD), especially for erosive esophagitis. Although non-erosive reflux disease (NERD) is probably associated with obesity or other metabolic syndrome, there is little direct evidence to support this assertion.

METHODS

Workers in Keio University who underwent a general health examination between September 2006 and August 2007 were enrolled. Reflux symptom questionnaires were administered and metabolic parameters were obtained. The severity of gastro-esophageal reflux (GER) was scored using a validated scale of videoesophagography.

KEY RESULTS

Two hundred and eighty-three subjects (243 men and 40 women; mean age 49.8 +/- 6.9 years) with no radiographic evidence of erosive esophagitis were enrolled. The severity of GER was worse among men than among women, whereas the severity of reflux symptoms was worse among women. The severity of GER was associated with age and serum triglyceride levels in men, and with the serum low-density lipoprotein cholesterol levels in women. The severity of reflux symptoms, however, was not associated with metabolic parameters. There were more women than men with reflux symptoms but without GER ('presumed' functional heartburn group), compared with subjects with neither GER nor reflux symptoms. In men, the presence of both reflux symptoms and GER ('presumed' NERD group) was associated with the serum triglyceride levels.

CONCLUSIONS & INFERENCES

While NERD is associated with serum lipid levels, functional heartburn is not. The prevalence of GER was greater among men; conversely, the prevalence of functional heartburn was greater among women.

Decreased gene expression of insulin signaling genes in insulin sensitive tissues of obese cats

Type 2 diabetes mellitus (DM) animal models have provided ample opportunity for investigating pathogenesis, as well as to evaluate novel treatment and prevention options for the disease. Because the domestic cat shares a similar environment with humans, it is also confronted with many similar risk factors for diabetes, such as physical inactivity and obesity. Obesity is a significant risk factor for diabetes in cats, and as such, the domestic cat may serve as an ideal model for investigating obesity induced insulin resistance. This study determined changes in insulin signaling genes within insulin sensitive tissues of obese felines. Quantitative RT-PCR was performed to determine mRNA levels of three important insulin signaling genes which have been implicated with insulin resistance: insulin receptor substrate (IRS)-1, IRS-2, and phosphatidylinositol 3'-kinase (PI3-K) p85alpha. Obese cats had significantly lower IRS-2 and PI3-K p85alpha mRNA levels in liver and skeletal muscle as compared to control cats. This down regulation of insulin signaling genes in obese cats mirrors that of obese humans and rodents suffering from insulin resistance. Interestingly, preprandial blood tests indicated that our obese cats were no different from control cats with regards to glucose tolerance and insulin resistance, thus indicating that the obese cats used in our study had a moderate level of obesity. Therefore, insulin signaling gene alterations were occurring in insulin sensitive tissues of moderately obese felines before glucose intolerance was clinically evident. As such, the monitoring of key insulin signaling genes may have some important diagnostic value to determine the risk level and degree of obesity induced insulin resistance.

Inhibition of angiogenesis by humulone, a bitter acid from beer hop

On the basis of our previous finding that humulone, a bitter acid from beer hop extract, was a potent inhibitor of bone resorption and inhibited the catalytic activity of cyclooxygenase-2 (COX-2) and more potently the transcription of the COX-2 gene, we examined the effect of humulone on angiogenesis, using chick embryo chorioallantoic membranes (CAMs) and vascular endothelial and tumor cells. Humulone significantly prevented in vivo angiogenesis in CAM in a dose-dependent manner with an ED(50) of 1.5 microg/CAM. Humulone also inhibited in vitro tube formation of vascular endothelial cells. Moreover, it suppressed the proliferation of endothelial cells and the production of vascular endothelial growth factor (VEGF), an angiogenic growth factor, in endothelial and tumor cells. Thus, humulone is a potent angiogenic inhibitor, and may be a novel powerful tool for the therapy of various angiogenic diseases involving solid tumor growth and metastasis.

Structure-activity studies of analogues of blomhotin mediating contraction of rat fundus

Blomhotin is a novel peptide (pGlu1-Gly2-Arg3-Pro4-Pro5-Gly6-Pro7-Pro8-Ile9-Pro10-Arg11) which has been isolated from the venom of Agkistrodon halys blomhoffii and exhibits contractile activity on rat stomach fundus. We carried out a structure-activity study of blomhotin and its related peptides, and the findings suggested that the N-terminal portion of blomhotin is mainly responsible for affinity for the blomhotin receptor, whereas the C-terminal portion of blomhotin, Pro-Ile-Pro-Arg, is responsible for complete activation of the blomhotin receptor in the rat stomach fundus. In particular, the amino acids at positions 9 and 11 of blomhotin appear to be essential for binding and intrinsic activity. Using knowledge gained from this structure-activity analysis, we have identified photoactive blomhotin analogues that have sufficient biological activity to probe the target molecule of blomhotin.

[Evaluation of MAST-26, newly developed system for the detection of IgE antibodies]

MAST-26 is a new allergy testing system which allows simultaneous determination of allergen-specific IgE antibody levels for 26 allergens using 200 microliters of patient serum. To evaluate the effectiveness of MAST-26 for the detection of allergen-specific IgE antibody, a total of 100 serum samples were collected from allergic patients at five facilities, and allergen-specific IgE antibody was measured by MAST-26. 14% of them were positive to > or = 10 allergens. If the patients had severe allergic symptoms, they were likely to show positive to many allergens. A good correlation was found between the results obtained by MAST-26 with those measured by CAP RAST and by intradermal skin test. It was concluded that MAST-26 is an effective screening method for the detection of allergen-specific IgE.

Amino acid sequence studies on cytolytic toxins from sea anemone Heteractis magnifica, Entacmaea quadricolor and Stichodactyla mertensii (Anthozoa)

The complete amino acid sequence of a cytolytic toxin, HmT, isolated from sea anemone Heteractis magnifica was determined. It is composed of 177 amino acid residues and lacks half-cystines. Partial N-terminal sequences of three other cytolysins from Entacmaea quadricolor (EnT) and Stichodactyla mertensii (SmT-1 and SmT-2) were also determined. Comparing these sequences with those of other sea anemone cytolysins, a high degree of homology was observed.

High prevalence of sensitization to cat allergen among Japanese children with asthma, living without cats

BACKGROUND

Cat allergy is common among children with asthma. Many cat-allergic patients in Japan and elsewhere do not keep cats, but nonetheless become sensitized through environmental exposure to cat allergen.

OBJECTIVE

To assess the frequency of cat allergy and cat-specific immunoglobulin E (IgE) and immunoglobulin G (IgG) antibody responses in young Japanese patients with asthma in relation to self-reported cat exposure and Fel d 1 levels in dust samples.

METHODS

Cat dander-specific IgE antibody was measured in sera from asthma patients using the CAP system. IgE and IgG antibody to Fel d 1 was measured by antigen binding radioimmunoassay and by chimeric enzyme immunoassay. Fel d 1 levels in dust samples from a subset of patients' homes were measured by monoclonal antibody-based enzyme immunoassay.

RESULTS

Cat-specific IgE (CAP class>/=2) was found in sera from 70% of 44 patients who kept cats and 34% of 394 patients who had never kept cats. The prevalence of sensitization increased progressively to age 6 years (40%: positive), and then increased gradually to age 16 years (approximately 60%: positive) in patients who had never kept cats. There was an excellent correlation between cat CAP values and IgE levels to Fel d 1. The absolute amount of IgE antibody to Fel d 1 ranged from 0.01 to 15.6% of total IgE. Most patients who did not keep cats were exposed to Fel d 1 levels ranging from 0.07-8 microg/g dust.

CONCLUSIONS

Sensitization to cat allergen is common among young asthmatic patients in Japan, even among patients who do not keep cats. Use of CAP and the chimeric enzyme-linked immunosorbent assay allows accurate diagnosis of cat allergy and quantification of specific IgE antibody levels.

[Serum eosinophil cationic protein, urinary eosinophil protein X and urinary N-methylhistamine during acute asthma in children]

Serum eosinophil cationic protein (ECP), urinary eosinophil protein X (EPX) and urinary N-methylhistamine were investigated in 24 asthmatic children during acute asthma to determine the sequential variation in the parameters. Serum ECP levels and urinary EPX levels were high during acute asthma, and decreased gradually with improvement of acute asthma, however, these levels of eosinophil drived proteins were significantly higher than those in non-atopic children. There was no significant variation of urinary NMH levels. Significant inverse correlation was found between lung function and urinary EPX level. The present study suggests that serum ECP and urinary EPX may be useful for monitoring airway inflammation during acute asthma, and activation of eosinophils may persist after improvement of acute asthma.

[Food and food additives hypersensitivity in adult asthmatics. I. Skin scratch test with food allergens and food challenge in adult asthmatics]

OBJECTS

The aim of this study was to investigate in adult asthmatics, which kinds of food allergen can cause a positive reaction by skin scratch test and cause symptoms when administered as a food challenge.

SUBJECTS AND METHOD

Three thousand one hundred and two adult asthmatic patients were submitted to skin scratch tests with housedust mite. Japanese cedar extracts and 33 types of food. Sixty one adult asthmatic patients with a history of immediate, adverse reactions after food ingestion underwent open food challenge.

RESULT

Six hundred and twenty five of 3102 subjects (20.1%) had a positive test to one or more food allergens. The commonest food allergens were shrimp (27.7%), crab (27.7%), yeast (23.8%) and buckwheat (15.8%). The positive tests of shrimp, egg and cow's milk were highest in patients under 20 years and decreased with age, however the test rates of crab and soybean were not influenced by age. Positive food challenge responses occurred in 30/60 subjects (50%). The foods, which most of ten provoked a reaction, were buckwheat, shrimp, crab and bread.

CONCLUSION

Skin scratch test results in adult asthmatics were different from those in atopic children where the commonest foods with positive tests were egg, cow's milk and soybean. Except for patients with a previous life-threatening reaction. Food allergy should be diagnosed by food challenge where a patient's history of adverse reaction to food, positive skin test and RAST strongly support specific food reactivity.

[Slow-release theophylline for the treatment of asthmatic children]

The relative efficacy of theophylline therapy has been adequetely investigated for several decades. Benefits and risks from theophylline relate to serum concentration. Slow-release theophylline currently available in a variety of forms, including tablet, beaded capsule, granule, syrup and dry syrup. For children with chronic asthma requiring around-the-clock medication, slow-release formulations are more suited. Slow-release theophylline is likely to provide greater around-the-clock stabilization of hypersensitive airway and those given at night, provide effective control of nocturnal asthma symptoms. There is some variability between products and intrapatient variability on a day-to-day basis. Therefore therapeutic drug monitoring should be periodically conducted. There is increasing evidence for theophylline's anti-asthma properties, which include anti-inflammatory and immunomodulatory actions.

[Assay of specific anti-Chlamydia pneumoniae antibodies by ELISA method. 2. studies on clinical usefulness and serological diagnostic standards]

We measured anti-Chlamydia pneumoniae (C. pneumoniae) specific antibody titers by means of a newly-developed enzyme-linked immunosorbent assay (ELISA) method using an anti-C. pneumoniae specific antibody detection reagent. The clinical usefulness of this method was hereby evaluated. The IgG, IgA and IgM titers in 418 serum specimens obtained from patients with respiratory tract infections were measured by this new ELISA method, and the results were compared with the titers determined for the same specimens with the micro immunofluorescence (Micro-IF) method. The results showed good correlation coefficients for IgG, IgA and IgM. The two assay methods showed high agreement rates for positivity and for negativity. Specimens which did not yield the same results with the ELISA method and the Micro-IF method were subjected to analysis by the Western blot method, and the rates of agreement with the ELISA results were high. In addition, the child (0 approximately 15 yrs old; n = 122) and adult (16 approximately 90 yrs old; n = 133) cases were classified on the basis of being antigen-positive or antigen-negative at the initial examination, and their antibody-positive rates were determined. The adults showed no statistically significant differences in the antibody-positive rates for either IgG or IgA antibodies as a function of the pretreatment antigen status. However, the children showed statistically significant (p < 0.001) differences in the antibody-positive rates for both IgG and IgA antibodies as a function of the antigen status in the antigen-positive group compared with the rates in the antigen-negative group. Furthermore, the IgM-positive rates for the children were high in the antigen-positive group compared with the rates in the antigen-negative group, and the difference was statistically significant (p < 0.001). The IgM-positive rates in the adults were also significantly (p < 0.05) different between the antigen-positive group and the antigen-negative group. The Micro-IF method was applied to 34 specimens from antigen-positive patients, and 22 specimens were found to show an IgG titer of > or = 512 or an IgM titer of > or = 16. The diagnoses of these patients were acute respiratory disease in sixteen, pneumonia in four. Application of the ELISA-method to those 22 specimens showed all of them to exhibit IgG absorbance of > or = 0.6 and IgA absorbance of 0.2. The results described above indicate the clinical usefulness of our new ELISA method for the detection of antibodies specific for C. pneumoniae. The significance of this ELISA method for serological diagnosis of C. pneumoniae infections and the criteria for diagnosis of acute infections were also discussed.

[Clinical reliability of a new IgE detection system using chemiluminescent enzyme immunoassay named LUMIWARD immunoassay system]

The measurement of allergen-specific IgE antibodies and total IgE was performed with LUMIWARD immunoassay system (chemiluminescent enzyme immunoassay) using 406 serum samples obtained from patients with various allergic diseases and 81 serum samples from normal donors. These were collected by departments of internal medicine, pediatrics, dermatology and otorynolaryngology at eleven institutes in Japan. In addition to a comparative study with CAP RAST, skin tests were also performed to establish a clinical diagnosis. Simultaneous measurements were performed and an excellent correlation with CAP RAST was observed with a concordance rate of 92.6% and correlation coefficient of 0.922. The specificity determined by the normal serum samples was 96.4% for CAP RAST and 96.2% for LUMIWARD. The sensitivity determined by the samples, of which etiological allergens were identified clinically, was 84.8% for CAP RAST and 85.5% for LUMIWARD. Among them, the sensitivity of skin test was 91.8%. The concordance rate with clinical diagnosis was as high as 90.6% and 90.8% for CAP RAST and LUMIWARD. The normal upper limit of total IgE by cumulative 95% value was calculated to be 170 IU/ml for adult subjects. These results indicate the clinical usefulness of the LUMIWARD immunoassay system in evaluating IgE antibodies and total IgE.

[Diagnostic value of glass microfibre-based basophil histamine release test in food allergic children. Comparison with specific IgE antibody and skin scratch test]

We evaluated the diagnostic value of the glass microfibre-based histamine release test (HRT), which allows measurements to be performed using small amounts of whole blood, in 50 children with food allergy case histories. The patients were evaluated by radioallergosorbent tests (RAST), skin scratch tests (ST) and food challenge tests. Of the 50 patients, 39 had a confirmed clinical diagnosis of food allergy from food challenge tests and case histories, and were affected by a total of 60 positive allergens (egg 37, milk 11, soy beans 4, wheat 5, rice 3). The concordance, sensitivity, and specificity of HRT with the clinical diagnosis were 85.3%, 66.7% and 92.1%, those of RAST were 59.4%, 90.0% and 48.2%, and those of ST were 84.7%, 71.8% and 88.7%, respectively. The positive predictive values of HRT, RAST and ST were 75.5%, 38.8% and 66.7%. The false positive ratio of HRT (24.5%) was the lowest among all the tests. There was a significant correlation between HRT and RAST (r = 0.513, p < 0.001). However, the concordance of HRT with respect to RAST was 56.0%. The concordance and specificity of HRT in relation to the clinical diagnosis were higher than RAST and the same as ST. The sensitivity of RAST was higher than that of HRT. From these results, we concluded that RAST is good for the screening of allergens and that HRT is a useful diagnostic method for the confirmation of a clinical allergy.

Long-term survival in a patient with malignant carcinoid treated with high-dose octreotide

Octreotide acetate, a long-acting somatostatin analogue, is effective in controlling and markedly reducing the symptoms of carcinoid crisis. We report a patient with carcinoid syndrome with prolonged survival for 4.5 years with high dose octreotide therapy and survived for 7.5 years after the first flushing, in spite of episodes of severe carcinoid crisis. Dose escalation was required in order to control carcinoid symptoms, and the final dosage was 5,950 micrograms/day. Although administration of such a high dosage of octreotide has never been reported before, we found that octreotide could be used at this dosage safely without inducing serious side effects, and probably prolonged the patient's survival. Our experience with this case indicates that octreotide acetate is an effective drug in controlling carcinoid crisis and prolonging survival without serious side effects.

A case of myelodysplastic syndrome progressing to acute myelocytic leukemia in which adult-onset Still's disease had occurred 6 years before

A patient with adult-onset Still's disease who presented with myelodysplastic syndrome (MDS) after a course of 6 years is reported. To our knowledge, this is the first such reported case. The patient died of acute myelocytic leukemia. The possibility that cyclosporine contributed to the onset of MDS is discussed.

Treatment of disseminated intravascular coagulation with gabexate mesilate

Gabexate mesilate (FOY) was used to treat 215 patients with disseminated intravascular coagulation (DIC) and 146 patients with a predisposition to DIC (pre-DIC). Sixty percent of DIC patients and 48% of pre-DIC patients exhibited pretreatment organ failure, which resolved after FOY treatment in 16% of DIC patients and 17% of pre-DIC patients. Seventy percent of DIC patients and 49% of pre-DIC patients had a pretreatment bleeding tendency that was ameliorated by FOY treatment in 32% of DIC patients and 30% of pre-DIC patients. Comparison of pretreatment and posttreatment hemostatic studies of the DIC patients revealed that platelet count and levels of fibrinogen degradation products (FDP), thrombin-antithrombin-III complex, and FDP-D-dimer decreased significantly; fibrinogen level increased markedly; and prothrombin time was prolonged. DIC scores were significantly lowered in both leukemic and nonleukemic patients from the third day of treatment with FOY. Among leukemic DIC patients, 59% showed complete remission (CR), 21% partial remission (PR), and 7% exacerbation of their condition; 46% of the nonleukemic DIC patients demonstrated CR, 17% PR, and 17% exacerbation. Of the leukemic pre-DIC patients, 59% showed improvement and 7% exacerbation, whereas 55% of the nonleukemic pre-DIC patients showed improvement and 27% exacerbation.

[Pharmacokinetics and pharmacodynamics of hydrocortisone in asthmatic children]

Corticosteroids are very efficacious in the treatment of asthma. In the present study, the conversion rate of hydrocortisone succinate (HCS) to hydrocortisone in plasma was examined and pharmacokinetic study was carried out for the two compounds after a single intravenous injection of hydrocortisone sodium succinate (HCSS). Moreover, it was examined whether hydrocortisone improved acute asthmatic attacks. In a randomised cross-over trial at 5 to 7 days intervals, 10 asthmatic children aged 9-14 years were treated with a single intravenous injection of HCSS in a dose of 5 mg hydrocortisone/kg body weight or without HCSS. After 4-hour pulmonary function studies, they were received a subcutaneous injection of epinephrine (0.004 mg/kg). The plasma concentrations of HCS and hydrocortisone were measured by the HPLC and/or radioimmunoassay. The mean of maximum concentration of HCS was 26.38 mg/L. The concentration of HCS decreased rapidly with a half-life of 0.09 hr (5.38 min). The concentration of hydrocortisone reached to a peak value of 4.96 mg/L after 10 min, and then decreased with a half-life of 1.24 hour. It is predicted that an intravenous injection of HCSS every 6 hours in a dose of 5 mg hydrocortisone/kg would maintain hydrocortisone level at 100 to 150 micrograms/dl. HCSS did not show a rapid improvement of the pulmonary functions, but showed a tendency to improve the functions over 4 hours. Subcutaneous injection of epinephrine after HCSS resulted in a significant improvement of pulmonary functions compared to those by epinephrine alone. We concluded that hydrocortisone showed a slowly evolving improvement of pulmonary function and increased the responsiveness to beta-agonists.

[Assessment of the amount of drug deposited in the lungs of asthmatic children using disodium cromoglycate as the marker]

Disodium cromoglycate (DSCG) is easily absorbed from the airways and lungs, and is excreted unchanged in the urine and bile. Therefore it is possible to estimate the dose of DSCG deposited in the airways and lungs based upon urinary excretion. The urinary concentration of DSCG was measured by the HPLC method in 78 asthmatic children aged 0 to 16 years after they had inhaled 20 mg nebulizer solutions with facemasks. Jet-type nebulizers were used. The mean urinary excretion of DSCG in the patients aged 0, 1, 2 and 3 years from 4-hour urinary collection represented 0.204%, 0.231%, 0.593%, 0.790%, respectively, of the dose administered. In the patients aged 3, 4, 5-6, 7-9 and 10-16 years, from 24-hour urinary collection, the figures were 0.625%, 0.895, 0.855, 1.176%, 1.070%, respectively. The mean dose deposited in the airways and lungs of the age groups 0-1, 2, 3, 4-6, 7-9, and 10-16 years represented approximately 0.5%, 1.4%, 1.4-1.8%, 2.0%, 2.7%, 2.4%, respectively, of the dose administered. Although there was a wide range in the total amount of DSCG deposited in the airways and lungs of asthmatic children, these data seem to provide a useful guide to standardizing the dosing in inhalation therapy.

[Cyclosporine therapy of adult onset Still's disease with disseminated intravascular coagulation]

In April, 1991, a 61-year-old man was admitted to our hospital because of pancytopenia and disseminated intravascular coagulation (DIC). Five years prior to admission he had developed high fever, skin eruption and arthralgia which had been improved by antibiotics, but recurred. Steroid therapy was ineffective for pancytopenia and DIC. Laboratory findings were as follows: RBC count, 274 x 10(4)/microliters; WBC count, 470/microliters; Platelets, 6.4 x 10(4)/microliters; fibrinogen, 153mg/dl; FDP, 67.0 micrograms/ml; FDP-D.Dimer, 13040ng/ml; thrombin-antithrombin complex, > 60.0ng/ml; and plasmin alpha 2-plasmin inhibitor complex, 10.3 micrograms/ml. As we suspected adult onset Still's disease on the basis of clinical course, we treated him with methylprednisolone pulse therapy, which was, however, ineffective. leukocytopenia, thrombocytopenia and DIC improved after cyclosporine treatment. Since cyclosporine is known to be very effective to autoimmune diseases, we speculate that in this patient immunological mechanism may be involve in the pathogenesis of DIC.

[Clinical significance of IgG4 antibody determination in children against egg white, milk, soybean and Dermatophagoides farinae]

The measurement of IgE and IgG4 antibodies against egg white, milk, soybean and Dermatophagoides farinae was performed by FAST (fluorescence allergosorbent test) using 21 serum samples obtained from non-allergic children and 160 serum samples from atopic children with bronchial asthma and/or atopic dermatitis. Their antibody levels were evaluated for any association with disease severity and for clinical significance in establishing diagnosis. It was found that children with bronchial asthma showed lower levels of IgE antibodies against egg white, milk and soybean and higher levels of IgE antibodies against Dermatophagoides farinae compared with those of children with atopic dermatitis, while both groups showed higher levels of egg white and milk-specific IgG4 antibodies compared with non-allergic children. These IgE and IgG4 antibody levels revealed a tendency to correlate with disease severity in patients with atopic dermatitis, while this was not observed in patients with bronchial asthma. The contribution percentages of IgG4 antibody determination, together with IgE antibody determination, in retrieving causal allergens were 71% for egg white, 70% for milk and 48% for soybean allergy, implying their diagnostic value in establishing clinical diagnosis.

[Classification of allergens by positive percentage agreement and cluster analysis based on specific IgE antibodies in asthmatic children]

Classification and characterization of allergens is important because allergic patients are sensitized by a variety of allergens. One hundred and sixty-one sera from asthmatic children were investigated for specific IgE antibodies against 35 allergens including 20 inhalants and 15 foods by means of the MAST method. We assessed the allergenic properties of the allergens based on positive percentage agreement and cluster analysis. There was a high positive percentage agreement of specific IgE antibodies between house dust and Dermatophagoides spp., a relatively high agreement between 5 molds, cat and dog epithelium, mugwort and wormwood and 5 grasses. Among the food allergens, the positive percentage agreements were relatively high, especially between cow's milk, casein, cheese, and between 3 cereal grains. In the cluster analysis, house dust and Dermatophagoides spp. made a big cluster; therefore 32 allergens except house dust and mites were analyzed. From the results of the cluster analysis, the major cluster consisted of (1) ragweed, (2) mugwort and wormwood, (3) timothy, sweet vernal, velvet and cultivated rye, (4) wheat, barley and rice, (5) molds, (6) cow's milk, casein, soybean and cheese, (7) shrimp and crab, (8) egg white, (9) Japanese cedar, (10) dog epithelium, (11) cat epithelium. The cluster of grass pollens and cereal grains made one cluster. These results tend to confirm the presence of species cross-reactivities within the major classes of allergens.

Late-onset homozygous protein C deficiency manifesting cerebral infarction as the first symptom at age 27

We report a 31-year-old female who had repeated thrombosis and was diagnosed as having congenital homozygous protein C deficiency based on decreased protein C antigen and activity, and the findings of family history. This patient had shown no symptom of thrombosis until the age of 27 years, when she had cerebral infarction as the first symptom. Low molecular weight heparin was useful for disseminated intravascular coagulation (DIC) that complicated protein C deficiency in this patient.

[Evaluation of Oriton IgE, a new kit for measurement of allergen specific IgE antibodies]

To determine whether Oriton IgE kit, a new kit for the measurement of allergen-specific IgE antibodies, is useful in screening allergen-specific antibody, we measured the titers of IgE antibodies against 11 different allergens (house dust 2, Dermatophagoides farinae, Japanese cedar, ragweed pollen, egg white, milk, cat epithelium, dog epithelium, Candida, Alternaria and Aspergillus) with the Oriton IgE kit, and the results were compared to those of intradermal tests and RAST in 103 allergic patients and 10 normal subjects. There was a clear correlation between IgE antibody titers measured by the Oriton IgE kit and the RAST. The correlation coefficient was 0.76 (p less than 0.01) and the total correspondence rate was 85.9%. We also found strong correlation between the Oriton IgE kit and RAST in IgE antibody titer against 5 different allergens, Dermatophagoides farinae, Japanese cedar, ragweed pollen, egg white and Candida. The correlation coefficient was over 0.70. The correspondence rate, sensitivity and specificity of the Oriton IgE kit to intradermal tests was 71.8%, 45.3% and 87.8% respectively. The sensitivity of the Oriton IgE kit was slightly higher, while the specificity was slightly higher in RAST, although the differences were not statistically significant between these methods. Correspondence rate of the Oriton IgE kit was similar to that of RAST. These results suggested that the Oriton IgE kit is useful in screening allergen specific IgE antibodies.

Homozygous protein C deficiency: identification of a novel missense mutation that causes impaired secretion of the mutant protein C

We analyzed the promoter region and all the coding exons and exon-intron boundaries of the protein C gene in a Japanese patient with recurrent thromboembolism and complete protein C deficiency. By sequencing these fragments we identified a previously undescribed mutation. A guanine residue was replaced by an adenine residue converting Gly-292 (GGC) to Ser (AGC) in the last exon coding for the catalytic domain. Substitution of this key amino acid, invariably conserved in the serine protease superfamily to which protein C belongs, probably leads to destabilization of the tertiary structure. In a transient expression assay with COS 7 cells, the protein C level was extremely low in the culture medium of the cells transfected with the mutated protein C expression vector, as compared with the normal vector. In contrast, the cell extracts contained similar amounts of mutant and normal protein C, suggesting impaired secretion of the mutant protein C. Using mutagenic primers to introduce a new PvuII site into the mutant allele, we made a study of the family members in this patient's pedigree, revealing that the mutant allele had been inherited in the affected individuals in this pedigree.

[CML with autoimmune thrombocytopenia observed in the course of IgG (kappa) type monoclonal gammopathy]

An 80-year-old male with IgG (kappa) type benign monoclonal gammopathy was admitted to our hospital because of marked leukocytosis. At the time of admission, thrombocytopenia was also noted. A bone marrow aspirate showed marked granulocytosis with a normal megakaryocyte count. PAIgG was elevated and the NAP score was low. Ph1 chromosome and rearrangement of the breakpoint cluster region were detected. On the basis of these findings, he was diagnosed as having CML with autoimmune thrombocytopenia. This case was of interest with respect to blood cell differentiation and immunological findings.

[Studies on C1 inactivator resistant fibrinolytic activity]

The fibrin lysis activity in the presence of enough quantity of C1 inactivator (C1.INA) is called C1.INA resistant fibrinolytic activity (C1.IRFA). C1.INA inhibits the activation of intrinsic fibrinolysis, therefore C1.IRFA is considered to reflect the extrinsic fibrinolytic activity mainly. We studied the effect of C1.INA using fibrin plate assay on fibrin lysis activity (FLA) and C1.IRFA in normal individuals and pregnant women, and studied the fluctuation of FLA and C1.IRFA during venous occlusion test (VO) or 1-deamino-8-D-arginine vasopressin (DDAVP) administration. After VO or DDAVP administration, the euglobulin lysis time (ELT) was reduced, FLA increased and C1.IRFA also increased. The increase in C1.IRFA accounted for most of the increase in FLA. Therefore, the increased fibrinolytic activity during VO or DDAVP administration is due to extrinsic fibrinolytic activity. In the pregnant women, the fibrinolytic activity was decreased during pregnancy and the low fibrinolytic activity is suggested to be involved in the low extrinsic fibrinolytic activity. The measurement of C1.IRFA is considered to be useful.

[Plasminogen activator in leukemic cell homogenate]

We examined fibrinolytic substances in homogenate of leukemic cells, normal granulocyte or mononuclear cells fraction. Plasminogen activators (PA) were significantly low in normal cells, but they were slightly increased in lymphoblastic leukemia cells and markedly increased in myeloblastic leukemia cells. In almost leukemic cells homogenate, the antigen ratio of tissue type PA (t-PA)/urokinase type PA (u-PA) was about 2.0. In especially AMMoL and AMoL, PA activity had discrepancy between euglobulin lysis time and amidolytic assay using chromogenic substrate. As PA inhibitor (PAI)-II was markedly increased in them. PAI might effect the PA assay. PA activity of leukemic cells homogenate was similar to that without t-PA stimulator and leukemic cells homogenate significantly stimulated t-PA. As both PA activity and antigen were statistically increased in leukemic cells homogenate of patient with disseminated intravascular coagulation (DIC), PA and PA stimulator in leukemic cell might play an important role in hypofibrinogenemia or DIC.

[Elevated levels of cytokines in plasma from patients with disseminated intravascular coagulation]

We measured blood concentrations of tumor necrosis factor (TNF), interleukin-1 beta (IL 1-beta), soluble interleukin 2 receptor (s-IL 2r), and interferon alpha (IFN alpha) in 30 patients with disseminated intravascular coagulation (DIC) and compared the results to those of 25 patients without DIC. Plasma levels of TNF, IL 1-beta, and s-IL 2r were higher in patients with DIC than in those without DIC. In one case of acute promyelocytic leukemia, plasma levels of TNF and IL-1 beta increased at the onset of DIC but decreased upon DIC improvement. These findings suggest that activation of the immune system is involved in the development of DIC. However, these concentrations were not markedly increased in patients with leukemia, although blood TNF and s-IL 2 r were markedly elevated in patients with solid cancers. Especially in patients with solid cancers, hyperactivation of the immune system may cause an increase in blood TNF and IL-1 beta and the development of DIC.

[Measurement of FDP-D-dimer in DIC and pre-DIC]

We measured FDP-D-dimer value in disseminated intravascular coagulation (DIC), pre-DIC (within 7 days before onset of DIC) and suspected DIC (not completely satisfying the DIC criteria). The level of FDP in many patients with pre-DIC was normal, but the level of FDP-D-dimer in most patients with pre-DIC was increased. FDP was markedly increased one day before onset of DIC but FDP-D-dimer was increased 7 days before the onset. FDP was significantly higher in DIC than in pre-DIC, but it was not higher in pre-DIC than in suspected DIC. In patients with hematological malignancies, FDP-D-dimer was statistically higher in DIC than in pre-DIC and in pre-DIC than in suspected DIC, but in non-hematological malignancies, FDP-D-dimer was not significantly different among the 3 groups. The peak increase of FDP-D-dimer was noted at a DIC score of 7 or 8. The correlation of FDP-D-dimer with FDP was better in pre-DIC than in DIC, and the ratio of FDP-D-dimer to FDP was higher in pre-DIC. FDP-D-dimer was not correlated with fibrinopeptide A or B beta 15-42 in pre-DIC. It is speculated that pre-DIC is a hypercoagulable state and FDP-D-dimer may be useful to the diagnosis of pre-DIC.

[Availability of DDAVP in hemostasis control for the breast tumor resection in a patient with thrombasthenia (type II)]

We reported a 33-year-old woman with thrombasthenia (type II) in whom 1-deamino-8-D-arginine vasopressin (DDAVP) was available for the hemostasis control during breast tumor resection. She has had recurrent nasal bleeding and purpura since 2 years old. On the first admission to our hospital because of hematuria at 18 years old, she was diagnosed as thrombasthenia (type II) from hemostatic studies. At 20 years old, she had a healthy baby by the cesarean section with transfusion of fresh blood and platelet concentrates. On the 5th admission for the breast tumor resection, defect of glycoprotein II b-III a of her platelets was confirmed by using SDS gel electrophoresis. Recently, there are some reports on availability of DDAVP for hemostatic control in platelet dysfunction of various etiologies as well as mild hemophilia and von Willebrand disease. So, DDAVP (0.4 microgram/kg) was used for hemostasis control. After 1 hour, the bleeding time was shortened from over 10 to 4 min, platelet adhesiveness to glass beads increased from 1.8 to 37%. Furthermore, the levels of Ristocetin cofactor and von Willebrand factor antigen (especially large multimer) also increased. But platelet aggregation with various inducers remained unchanged before and after infusion. Breast tumor (fibroadenoma) resection.

[A case of tracheopathia osteoplastica]

A case of tracheopathia osteoplatica in a 43-year-old man, detected incidentally at the upper gastrointestinal examination was reported. The examination showed a long segment esophageal compression from a paraesophageal lesion. CT was effective to demonstrate the typical narrowing and wall thickening of the trachea, and to demonstrate that the esophageal compression was caused by the deformed trachea.

Leukotriene C4 in children with atopic asthma. I. Plasma levels in acute asthma

The leukotrienes C4, D4 and E4 are potent biologic mediators, and are thought to play an important role in obstructive airways disease such as asthma. In this study, plasma immunoreactive LTC4 (iLTC4) levels in asthmatic children were measured using radioimmunoassay after Sep-pak extraction in order to determine whether LTC4 is released in vivo during an asthmatic attack. In 10 non-atopic children, the mean +/- SEM of plasma iLTC4 level was 0.031 +/- 0.013 pmol/ml. Significantly higher plasma iLTC4 levels were recognized at all stages in asthmatic children, both in remission (p less than 0.01) and during an attack (p less than 0.01). PaO2 levels during an attack were significantly lower in the high iLTC4 group. In 15 asthmatic children, the plasma iLTC4 levels during an attack (0.134 +/- 0.017 pmol/ml) significantly decreased during recovery (0.078 +/- 0.012 pmol/ml) (p less than 0.05). Plasma iLTC4 levels correlated closely with lung function (p less than 0.01). The high iLTC4 levels in plasma in asthmatic children suggest a role for LTC4 in the pathophysiology of asthma.

Leukotriene C4 in children with atopic asthma. II. Plasma levels in bronchial challenge with specific allergen

Peptide leukotrienes C4, D4 and E4 are considered to be major mediators of hypersensitivity reactions. In this study, immunoreactive leukotriene C4 (iLTC4) in plasma, taken from asthmatic children who had undergone bronchial challenge with a specific allergen, was measured using radioimmunoassay in order to determine whether LTC4 is released in vivo during human allergic reactions. With regard to the bronchial challenge of 10 asthmatic children, plasma iLTC4 levels at the post-challenge stage (0.131 +/- 0.037 pmol/ml) were significantly elevated compared to the pre-challenge stage (0.065 +/- 0.016 pmol/ml) (p less than 0.01). The bronchial response was not directly related to the increased plasma iLTC4 levels, but the strength of the bronchial response did relate to the plasma iLTC4 levels at the pre-challenge (p less than 0.05) and post-challenge (p less than 0.01) states. The pre-challenge levels are relevant to bronchial reactivity, and the post-challenge levels are relevant to bronchoconstriction caused by exposure to allergens. The in vivo release of LTC4 following exposure to a specific allergen suggests that leukotrienes are important in the pathogenesis of asthma.

[Evaluation of allergen-specific IgE antibodies by a newly developed mast allergy system]

MAST, which stand for multiple antigen simultaneous test, uses enzyme-linked anti-human IgE and chemiluminogenic substate to determine IgE. This system is characterized by simultaneous analysis of multiple allergen items, up to 35, together with total IgE determination. We evaluated usefulness of this MAST system using 191 serum samples obtained from patients with bronchial asthma, allergic rhinitis and/or atopic dermatitis. It was found that there were statistically significant correlations between IgE antibody quantification by MAST and RAST in 24 out of 35 allergen items, with correlation coefficients more than r = 0.60. These included Dermatophagoides farinae and pteronyssinus, Japanese cedar pollen, orchard grass, Alternaria, Candida as inhalant allergens; egg white, milk, soybeans, wheat and rice as food allergens. It was also evaluated how many allergen-specific IgE antibodies could be detected in one serum sample. More than six allergen-specific IgE antibodies were simultaneously detected in 33% of 191 cases, indicating the importance of multiple-allergen analysis. These results indicate the clinical usefulness of the MAST allergy system in detecting IgE antibodies in allergic subjects.

[Pharmacokinetics and pharmacodynamics of sustained-release theophylline formulation, Slo-bid, in both single and multiple dosing studies of asthmatic children]

The pharmacokinetics of theophylline in serum and saliva, and the pulmonary functions were examined in seven asthmatic children aged 9-14 years in both single (6.7 +/- 0.8 micrograms/kg) and multiple dosing settings of sustained-release theophylline formulation, Slo-bid, designed for 12-hour dosing intervals. In the single dose study, the mean maximum concentration (Cmax) and the time taken to reach maximum concentration (Tmax) in serum were 5.5 micrograms/ml and 7.3 hours, and the same parameters in saliva were 3.8 micrograms/ml and 7.3 hours. In the multiple dose study which lasted five days, Cmax, the mean minimum concentration (Cmin), the peak-trough fluctuation (delta P-T) and Tmax in plasma were 13.2 micrograms/ml, 9.9 micrograms/ml, 3.3 micrograms/ml and 5.4 hours, and those in saliva were 10.4 micrograms/ml, 7.0 micrograms/ml, 3.4 micrograms/ml and 5.0 hours, respectively. These results, showing a significant correlation, in both single and multiple dose trials, between the theophylline concentration in serum and the improvement of pulmonary function are support the contention that the therapeutic range of theophylline concentration in serum is 5 to 20 micrograms/ml. There was a significant correlation between the concentration in serum and saliva (r = 0.943, p less than 0.001). The predicted concentrations in serum from those in saliva were +/- 3 micrograms/ml of the measured concentrations in 92.8% of measurements. From these results, we concluded that the sustained-release formulation of theophylline, Slo-bid, is suitable for the treatment in asthmatic children.

Successful treatment with a long-acting somatostatin analogue (SMS201-995) in a patient with malignant carcinoid syndrome

A case of carcinoid syndrome is presented. Pulmonary adenosquamous carcinoma with hepatic metastasis was found in a 60-year-old Japanese male who was complaining of fever, cough and haemosputum. After the treatment with 5-fluorouracil (5-FU) over 2 years, he was diagnosed as carcinoid syndrome on the appearance of facial flushing, face edema and watery diarrhea accompanied by high levels of 5-hydroxyindole acetic acid (5-HIAA) in blood and urine. Prednisolone, which was initially effective, was replaced by SMS201-995 due to the considerable dose increase of the former because its effect became insufficient during the course of the treatment. Clinical symptoms were improved by SMS201-995 and blood 5-HIAA level decreased gradually but markedly. Thus better results were obtained by SMS201-995 compared with prednisolone. These results imply that SMS201-995 is appreciated as an effective drug for treatment of carcinoid syndrome.

Hydrocortisone succinate and hydrocortisone simultaneously determined in plasma by reversed-phase liquid chromatography, and their pharmacokinetics in asthmatic children

Hydrocortisone succinate and hydrocortisone are chromatographed with a mobile phase consisting of sodium acetate/acetonitrile (77/23, by vol), the effluent being monitored at 254 nm. p-Hydroxybenzoate-N-propyl is used as the internal standard. Detection limits are 0.5 mg/L for hydrocortisone succinate, 0.2 mg/L for hydrocortisone. For five different concentrations the respective mean analytical recoveries were 88.2% and 100.5%, the mean intra-assay CVs for slope 3.9% and 2.1%, and the inter-assay CVs 3.3% and 1.6%. Simultaneous measurement of hydrocortisone and its succinate ester may be useful for pharmacokinetic study. Concentration-time profiles for plasma after administration of hydrocortisone sodium succinate are presented.

Hydrocortisone succinate and hydrocortisone simultaneously determined in plasma by reversed-phase liquid chromatography, and their pharmacokinetics in asthmatic children

Hydrocortisone succinate and hydrocortisone are chromatographed with a mobile phase consisting of sodium acetate/acetonitrile (77/23, by vol), the effluent being monitored at 254 nm. p-Hydroxybenzoate-N-propyl is used as the internal standard. Detection limits are 0.5 mg/L for hydrocortisone succinate, 0.2 mg/L for hydrocortisone. For five different concentrations the respective mean analytical recoveries were 88.2% and 100.5%, the mean intra-assay CVs for slope 3.9% and 2.1%, and the inter-assay CVs 3.3% and 1.6%. Simultaneous measurement of hydrocortisone and its succinate ester may be useful for pharmacokinetic study. Concentration-time profiles for plasma after administration of hydrocortisone sodium succinate are presented.