[Two cases of acute eosinophilic pneumonia--analyses of cytokines in BALF before and after treatment]

Acute eosinophilic pneumonia (AEP) has been well recognized as sudden onset respiratory failure characterized by an increased eosinophilic cell count in the bronchoalveolar lavage fluid (BALF). Although several lines of research have demonstrated that the Th2 cytokine network is likely to play a pivotal role in the development of AEP, that mechanism has not been clearly understood yet. Previous reports published in Japan demonstrated that the BALF CD4/CD8 ratio in patients with AEP ranged between 1.1 and 5.8. In this report, we describe 2 cases of AEP in which the CD4/CD8 ratios were 0.3 and 7.8 when present. We measured IL-4, IL-5, IL-10 and IFN gamma in the BALF before and after treatment in these patients. IL-5 decreased drastically after the treatment phase, while the other cytokines did not change much. We concluded that the IL-5 concentration in the BALF is probably related to the development of AEP. In addition, we also speculated that the CD4/CD8 ratio in BALF from patients with AEP may be affected whether a patient has an atopic background or not.

[Results of surgery in Mycobacterium avium complex pulmonary disease]

Recently, several studies have revealed the usefulness of surgical therapy for nontuberculous mycobacterial (NTM) disease. We have encountered and taken many opportunities for surgical therapy in Mycobacterium avium complex (MAC) disease. From April 1995 through March 1999, 14 patients with MAC disease underwent 16 pulmonary resections. NTM was diagnosed at our hospital in all subjects according to the criteria of the American Thoracic Society. There were 8 women and 6 men, with a mean age of 54 years. The most common indications for surgery were localized lesion (7 cases), severe symptoms (5 cases) and progressive disease (2 cases). Twelve patients were receiving multidrug chemotherapy, 10 of whom were also receiving clarithromycin. The mean period of preoperative chemotherapy was 17 months. Ten patients had a variety of symptoms, with some combination of cough, sputum, hemosputum, dyspnea, fever and anorexia. About 30% of the symptoms were improved after preoperative chemotherapy. The symptoms disappeared in all except one patient, who underwent pneumonectomy. After surgery, all patients attained a sputum-negative status. Nine patients underwent 11 partial resections, comprising 3 thoracotomies and 8 video-assisted thoracic surgeries (VATS). There was no operative mortality. Re-operation was performed in a patient with bronchopleural fistula after initial surgery. Currently, 2 months after the last operation, we have encountered no other severe complication and no relapse. Surgery may play an important role in treatment of MAC disease. We recommend partial resection with VATS for localized MAC disease.

[A case of malignant lymphoma showing a stratum of lymphoma cells]

A 74-year man suffered an artificial pneumothorax of the right lung because of pulmonary tuberculosis 41 years before. He was admitted, and enlargement of chronic pyothorax was noted in chest radiography in 1998. A 67Ga scintigram revealed uptake at the site of the chronic pyothorax. Cytological findings of the pleural effusion included many atypical lymphocytes. We suspected the presence of a malignant lymphoma and performed a biopsy under thoracoscopy, but could not arrive at a diagnosis. Therefore, resection of the chronic empyema was performed. Histological examination demonstrated the layer of lymphoma cells covering the wall of empyema between the layers of necrotic and connective tissue. Lymphoma cells were stained with L 26, which is known as a B cell marker. We diagnosed diffuse large cell lymphoma (B cell type). No case like this case has ever been published of malignant lymphoma bearing a layer of lymphoma cells. This case is thought to show early-phase malignant lymphoma complicated with chronic pyothorax after artificial pneumothorax. Malignant lymphoma should be suspected when chronic pyothorax undergoes enlargement, even if CT scanning or MRI does not show typical findings.

[Three cases of Mycobacterium avium lung disease in an iron foundry]

We report three cases of M. avium lung disease, all occurring in the same iron foundry over a 5-year period. Case 1: A 38-year-old man was admitted to our hospital because of abnormal chest x-ray shadows observed during a routine checkup. M. avium complex was isolated from the sputum and a CT scan showed multiple nodular shadows with cavities. Case 2: A 63-year-old man presented with dyspnea. Chest CT showed nodular shadows in both upper lobes. M. avium complex was isolated from his sputum. Case 3: A 62-year-old man was hospitalized for treatment of diabetes mellitus. A nodular cavitary shadow* OK?* in the right upper lobe was observed in the radiograph. CT scanning demonstrated a nodular shadow with thick pleural indentation. M. avium was isolated from the sputum and gastric juices. There were similarities in the radiographic findings in all cases: nodular shadows with cavities in the upper lung fields. These findings differed from those in another M. avium infection in the lung which occurred in a middle-aged woman. We suspected inhalation of an aerosol contaminated by M. avium complex. There have hitherto been no reports of group infections in healthy persons. We suspected the same environmental source for the infection.

[A case of pulmonary tuberculosis complicated with multiple bone and joint tuberculosis]

A 29-year-old male complaining of fever and general fatigue was admitted to our hospital. On admission chest X-ray showed infiltrative shadows with cavities in the bilateral lung apical areas, and sputum examination for acid fast bacilli was smear positive, Gaffky 1. He was treated as pulmonary tuberculosis (TB), and chest X-ray findings and sputum examination improved after a few months of treatment with antituberculous chemotherapy (INH, RFP, EB, PZA). However, tuberculous cold abscess appeared in retropharyngeal area, subcutaneous tissue of thoracic cage and retroperitoneal space, and shortly later, bone and joint TB were recognized in shoulder and wrist joints and vertebrae. The findings of vertebral foci were not recognized by a simple X-ray picture of vertebrae. at that time, but MRI of vertebrae showed low intensity areas with ring enhancement in the cervical, thoracic and lumbar vertebrae. Despite treatment with antituberculous agents, new bone and joint TB had developed in many tissues and had accompanied with cold abscess in adjacent tissue, whereas pulmonary TB had improved after the initial transient worsening. The appearance of bone and joint TB was most probably caused by the initial transient worsening of hidden bone and joint TB as a part of the initial systemic transient worsening of tuberculosis. After treatment for 4 months, pulmonary TB as well as bone and joints TB had improved. Tuberculous cold abscess in retropharyngeal may be secondary to cervical vertebral TB but is now rarely seen. In this case, involvement in many tissues such as retropharyngeal area, subcutaneous tissue of thoracic cage and retroperitoneal space were seen, and these findings are now uncommon and usually represents involvement secondary to contiguous infection.

[Pulmonary infection caused by Mycobacterium gordonae in immunocompetent patient]

We report a case of 67-year-old female immunocompetent patient admitted to our hospital because of hemoptysis. Computed tomography (CT) of the lung showed bronchiectasis in the right S5 and small nodules in the right S6 and left S5. The cultures of sputum and bronchial washing specimen repeatedly revealed acid-fast bacilli identified as Mycobacterium gordonae (M. gordonae) by DNA-DNA hybridization (DDH) method. Thus, she was diagnosed to be infected with M. gordonae. She was treated with isoniazid, rifampicin, ethambutol and streptomycin. After treatment, the cultures of sputum and bronchial washing specimen converted to negative, and the chest CT showed improvement of small nodules. M. gordonae is a nontuberculous mycobacterium of very low pathogenic potency. Recently there have been a few reports of infection by M. gordonae not only in immunocompromised patients but also in immunocompetent patients. These cases were considered to be sensitive to initial standard antimycobacterial therapy, therefore, it is important to examine for M. gordonae in cases suspected of nontuberculous mycobacterial infection.

Bronchial brushing cytology features of primary malignant fibrous histiocytoma of the lung. A case report

BACKGROUND

Malignant fibrous histiocytoma (MFH) of the lung is rare. Early diagnosis is very important because of its poor prognosis. Long-term survivors of pulmonary MFH are patients who had surgical resection. When the patient can undergo surgery after a prompt diagnosis, the prognosis improves more than with other therapy. However, it is not easy to establish the diagnosis of thoracic MFH. In general, the small fragments from bronchial or percutaneous transthoracic fine needle aspiration (FNA) biopsies are inadequate for cytologic or pathologic analysis. Bronchial brushing cytology is greatly superior to FNA cytology because one can obtain a large amount of cells. Therefore, bronchial brushing cytology may play a useful role in diagnosis when endobronchial involvement is found.

CASE

A 65-year-old female was admitted with a cough, yellow sputum and exertional dyspnea. A chest roentgenogram showed a 12 x 12-cm mass in the left lung field. Bronchial brushing cytology revealed many fibroblastlike, histiocytelike, bizarre and multinucleated giant cells in a background of necrosis. Atypical mitotic figures were also found. The cytologic findings strongly suggested MFH. Although the pathologic findings from FNA biopsy showed storiform clusters structured by pleomorphic, fibroblastlike cells with bizarre nuclei and mitotic figures, the material was too small to diagnose it definitively. Six months later the patient died. An autopsy confirmed the diagnosis of MFH: the typical storiform clusters were composed of many fibroblastlike and histiocytelike cells that were positive for CD68 (PGM1) antibody.

CONCLUSION

Bronchial brushing cytology may be a useful method for early, definitive diagnosis of MFH. The presence of pleomorphic, spindle-shaped fibroblastlike and histiocytelike cells with the clusters showing a storiform pattern may permit the diagnosis of MFH.

[Matured mediastinal teratoma with a giant cyst resembling pleural effusion on X-ray films]

A 23-year-old man complaining of right-sided chest pain was admitted to our hospital for further examination of an abnormal shadow on chest X-ray films. Initially, we suspected the abnormal shadow was that of a pleural effusion in the right thorax. Computed tomographic scans disclosed a tumor in the anterior mediastinum, adjacent to the abnormal shadow. After closer examination, particularly by fluoroscopy on catheterization, we recognized that the abnormal shadow was a giant cyst, and that it connected with a solid mass. There were no abnormal laboratory data on admission. An examination of fluid specimens from the giant cyst revealed high levels of the tumor markers SCC antigen, CEA, and CA 19-9. These findings together suggested that the solid mass with giant cyst might be a mediastinal teratoma. The tumor was completely resectable without serious complications. The giant cyst contained 1,200 ml of fluid, and occupied half the volume of the right thoracic cavity. Pathological examination disclosed that the resected mediastinal tumor was a matured teratoma. Although matured teratoma are often composed of cysts, those that radiologically resemble pleural effusion, as in this case, were considered uncommon.

[Assessment of beta-methyl lodophenyl pentadecanoic acid myocardial scintigraphy in patients with chronic pulmonary diseases]

The purpose of this study was to determine whether impaired fatty acid metabolism occurs in the right ventricle of patients with chronic pulmonary diseases (TB sequelae, TB seq.; 8, and chronic pulmonary emphysema. CPE; 14). 123I-BMIPP myocardial scintigraphy was performed on 22 subjects. The RV-BMIPP index (ratio of radioactivity in the right ventricle to that in the upper mediastinum), LV-BMIPP index (ratio of radioactivity in the left ventricle to that in the upper mediastinum), and RVc/LVc (ratio of radioactivity in the right ventricle to that in the left ventricle) were calculated to compare the distribution of radioactivity in the right and left ventricles. We also examined the correlations between these parameters and parameters of blood gas analysis and pulmonary hemodynamics. The RV-BMIPP index. LV-BMIPP index, and RVc/LVc were elevated in the TB seq. and CPE patient groups compared to the control group. The RV-BMIPP and LV-BMIPP indices demonstrated significant, negative correlations with PaO2; also a significant positive correlation was observed between the RV-BMIPP index and mean pulmonary arterial pressure. On the other hand, no significant correlation was found between the LV-BMIPP index and mean pulmonary arterial pressure. In the arm-stretching test under right heart catheterization, the RV-BMIPP and LV-BMIPP indices demonstrated significant, positive correlations with the cardiac index during exercise. These results suggest that hypoxemia accelerates fatty acid metabolism in the myocardium, and that local pressure overloading accelerates fatty acid metabolism in the right ventricle. Anomalies of fatty acid metabolism in the right ventricle may appear in patients with chronic pulmonary disease, and could be an adaptation to hypoxemia and overload, not an impairment.

Mechanism of endothelium-dependent vasorelaxation evoked by lysophosphatidylcholine

Vasorelaxation induced by lysophosphatidylcholine (LPC) and platelet activating factor (PAF) was examined in rings isolated from rat aorta and mesenteric artery. LPC caused dose-dependent vasodilatation, which was sensitive to CV-6209, a PAF antagonist, and NG-monomethyl-L-arginine, a nitric oxide synthase inhibitor, but insensitive to indomethacin. PAF (10(-7)M) caused a tachyphylactic effect in mesenteric artery, but no tachyphylactic effect was demonstrated with LPC. Vasorelaxation patterns with LPC differed from those with PAF in the rat mesenteric artery. These results suggest that LPC-induced vasorelaxation may involve increased nitric oxide production mediated by the PAF receptor pathway, another receptor pathway possibly blocked by CV-6209, or PAF itself produced in endothelial cells in response to LPC.

[Changes in atrial natriuretic peptide and pulmonary hemodynamics induced by exercise in patients with chronic pulmonary emphysema]

We studied the changes in pulmonary hemodynamics induced by arm-stretching exercise in 12 patients with chronic pulmonary emphysema (CPE) and 9 control subjects (Controls). Both patients and control subjects underwent right heart catheterization with inspired gas analysis at rest and during exercise for the 6 minute-exercise test. Mean pulmonary arterial pressure (mPAP) in patients with CPE significantly increased from 18.5 +/- 3.9 mmHg at rest to 25.7 +/- 5.1 mmHg during exercise without decreased oxygen tension of the arterial blood. Both mPAP and total pulmonary resistance increased in proportion to the increases in cardiac output. Mixed venous plasma atrial natriuretic peptide (ANP) was significantly evaluated during exercise in patients with CPE, but did not in Controls. There were a significantly positive relationships between ANP and mPAP, and a significantly negative relationships between ANP and PvO2 during exercise. These results suggest that pulmonary hypertension during light exercise in cases of CPE may be caused by deterioration of the pulmonary capillary bed, and that ANP may be a useful indicator for evaluating pulmonary hypertension in patients with CPE.

Enhanced expression of heparin-binding EGF-like growth factor and its receptor in hypertrophied left ventricle of spontaneously hypertensive rats

OBJECTIVES

Although heparin-binding epidermal growth factor-like growth factor (HB-EGF) is thought to produce hypertrophy in isolated cardiomyocytes via an autocrine mechanism, the pathophysiological role of HB-EGF, in myocardial hypertrophy in vivo, is not yet known. To investigate the involvement of HB-EGF in cardiac remodeling associated with hypertension in vivo, we assayed the expression of HB-EGF mRNA and protein in the left ventricle (LV) during the development of left ventricular hypertrophy in spontaneously hypertensive rats (SHR).

METHODS

Prior to sacrifice and assay of HB-EGF and EGF-receptor (EGF-R) mRNA, morphologic and hemodynamic variables were measured in SHR and in age-matched Wistar Kyoto rats (WKY). At 5, 9 and 12 weeks of age, rats were killed, their hearts were removed, and the expression of HB-EGF and EGF-R mRNA and protein were measured. In addition, SHR and WKY were treated with enalapril, atenolol, or both for 4 weeks.

RESULTS

In untreated SHR, double products (i.e. systolic blood pressure (sBP) multiplied by heart rate (HR), an index of mechanical load, peaked at 9 weeks. Expression of HB-EGF mRNA was also observed to peak in these animals at 9 weeks, while expression of EGF-R mRNA increased from 5 to 9 weeks, but remained constant thereafter. In untreated WKY, double products and EGF-R mRNA expression did not change over time, whereas the level of HB-EGF message increased gradually. Antibody to HB-EGF reacted primarily with myocyte membranes in SHR, whereas antibody to EGF-R reacted mainly with interstitial cells in these animals. The angiotensin-converting enzyme inhibitor, enalapril, markedly decreased sBP in SHR, whereas the beta 1-adrenoreceptor antagonist, atenolol, significantly decreased HR. While neither alone affected the expression of HB-EGF mRNA, their combination significantly reduced the expression of HB-EGF mRNA, as well as double products, in these rats, but had no effect on expression of EGF-R mRNA.

CONCLUSIONS

The enhanced expression of HB-EGF mRNA and protein in LV of SHR suggest that this growth factor may play an important role during the early development of LV hypertrophy and cardiac fibrosis in SHR. The association between double products and HB-EGF expression suggest that the latter may be induced by increased mechanical load and may contribute, in turn, to cardiac remodeling.

Phase II study of irinotecan and etoposide in patients with metastatic non-small-cell lung cancer

PURPOSE

To determine the effects of irinotecan (CPT-11) given in combination with etoposide (VP-16) in metastatic non-small-cell lung cancer (NSCLC), to evaluate response and survival rates, and to determine the qualitative and quantitative toxicities of the combination chemotherapy.

PATIENTS AND METHODS

Sixty-one metastatic NSCLC patients received concurrent administration of CPT-11 and VP-16 for 3 days with recombinant human granulocyte colony-stimulating factor (rhG-CSF) support.

RESULTS

Fifty-nine patients were assessable for response and all 61 patients were assessable for toxicity and survival. Fifty-six patients were treated with two or more courses of chemotherapy. Thirteen patients achieved a partial response (PR), 36 showed no change (NC), and 10 showed progressive disease (PD). The overall response rate was 21.3% (95% confidence interval, 12.9% to 33.1%). The median duration of PRs was 141 days (range, 62 to 299). Of the hematologic toxicities, 14 (23%) and 24 (39%) patients experienced grade 3 or 4 leukopenia and neutropenia, respectively. The toxicities were feasible. Treatment-related death occurred in one patient who suffered hypovolemic shock induced by hematemesis. The median survival time was 10.0 months and the 1-year survival rate was 36.1%.

CONCLUSION

Combination chemotherapy with concurrent administration of CPT-11 and VP-16 with rhG-CSF support was only modestly effective against metastatic NSCLC, with feasible toxicities of moderate diarrhea and pulmonary toxicity. The results were equivalent to those expected with either cisplatin-based chemotherapy or with CPT-11 alone.

Enhancement of the cardiac beta-adrenergic system at an early diabetic state in spontaneously diabetic Chinese hamsters

Serial changes in cardiac norepinephrine content and the beta-adrenergic system were investigated during the development of cardiomyopathy in spontaneously diabetic Chinese hamsters (CHAD strain), in comparison to age-matched control Chinese hamsters (CHA) or non-diabetic CHAD hamster littermates. Cardiac norepinephrine content and beta-adrenergic receptor density significantly increased in short-term diabetics. These changes preceded both the development of cardiac hypertrophy and the enhanced response of adenylyl cyclase to isoproterenol plus 5'-guanylylimidodiphosphate [Gpp (NH)p], sodium fluoride, or forskolin stimulation. However, as the diabetic state developed cardiac norepinephrine content, beta-adrenergic receptor density, and adenylyl cyclase activity returned to control levels. The amount of stimulatory or inhibitory guanine nucleotide binding proteins in the diabetic group was similar to those in the control groups. These data suggest that the cardiac beta-adrenergic system is enhanced by the alterations in cardiac sympathetic activity during early diabetes, which are associated with the duration of diabetes rather than with the degree of hypertrophy or strain differences.

Antioxidant effects of calcium antagonists on rat myocardial membrane lipid peroxidation

We studied the antioxidant effects of nine calcium antagonists (nisoldipine, benidipine, nilvadipine, felodipine, nicardipine, nitrendipine, nifedipine, verapamil, and diltiazem) by means of rat myocardial membrane lipid peroxidation with a nonenzymatic active oxygen-generating system (DHF/FeCl3-ADP). The order of antioxidant potency of these agents was nilvadipine > nisoldipine > felodipine > nicardipine > verapamil > benidipine. Their IC50 values (microM) were 25.1, 28.2, 42.0, 150.0, 266.1, and 420.0, respectively. In contrast, nitrendipine, nifedipine, and diltiazem had little inhibitory effect on lipid peroxidation. These six calcium antagonists could be divided into four types on the basis of their antioxidant mechanisms. Nilvadipine, nisoldipine, and verapamil, which showed antioxidant effects both before and after the addition of active oxygen, and reduced the dihydroxyfumarate (DHF) auto-oxidation rate, were chain-breaking and preventive antioxidants. Felodipine, which showed antioxidant effects both before and after exposure to active oxygen and increased the DHF auto-oxidation rate, was only a chain-breaking antioxidant. Nicardipine, which showed an antioxidant effect only before exposure to active oxygen and reduced the DHF auto-oxidation rate, was mainly a preventive antioxidant. Benidipine, which showed an antioxidant effect only before exposure to active oxygen and had no appreciable effect on the DHF auto-oxidation rate, could interrupt the chain reaction of lipid peroxidation at the initial step alone. Although these results suggest that the antioxidant properties of some calcium antagonists may be beneficial clinically in protecting against cellular damage caused by lipid peroxidation, further studies are required to establish the antioxidant effects of these agents in vivo.

Effect of endothelium of pulmonary artery vasoreactivity in monocrotaline-induced pulmonary hypertensive rats

This study investigated vasoreactivity modulated by endothelium in pulmonary arteries from isolated monocrotaline (MCT)-induced pulmonary hypertensive rats. The responses to KCl, 5-hydroxytryptamine (5-HT), acetylcholine (ACh), and nitroglycerin (NTG) were studied in the pulmonary artery with and without endothelium for 3 weeks following MCT-treatment. The sensitivity of the contractile response to KCl markedly increased in the arteries with endothelium at 2 and 3 weeks after treatment, but only slightly in the arteries without endothelium. In addition, the sensitivity of the contractile response to 5-HT peaked 2 weeks after treatment in the arteries with endothelium, but at 1 week in those without endothelium. Although the removal of endothelium shifted the concentration-response curve for KCl and 5-HT to the left both in the control state and at 1 week, it did not shift the curves at 2 or 3 weeks. The relaxation responses to ACh and NTG, indicative of endothelium-dependent and independent relaxation, respectively, as well as the content of tissue cGMP were reduced 2 weeks after treatment. These results suggest that the impairment of both the endothelium-dependent and -independent relaxation responses contributes to hyperreactivity of the pulmonary artery, and may in part contribute to the development of MCT-induced pulmonary hypertension.

[A case of Nothnagel syndrome]

A 72-year-old woman developed a sudden onset of bilateral ptosis, diplopia and gait disturbance. Neurological examination revealed bilateral oculomotor palsies, truncal ataxia, and transient slight weakness in the right upper extremity. She was diagnosed to have Nothnagel syndrome. T2-weighted MRI disclosed a high signal intensity lesion at the left paracentral portion of the upper midbrain in addition to the bilateral medial thalamic lesions, while brain CT showed only the thalamic lesions. Brain MRI was useful for detecting the small midbrain lesion.

A case of varicella-zoster myelopathy

INTRODUCTION

Early diagnosis of neurological complications of varicella-zoster virus (VZV) is important because of its treatability. We performed polymerase chain reaction (PCR) to detect VZV-DNA from the cerebrospinal fluid (CSF) of a patient with myelopathy.

PATIENT & METHODS

A 69-year-old man developed sensory disturbances in the lower extremities and bladder-bowel disturbances, followed by cutaneous zoster on his left arm. Polymerase chain reaction was applied to identify the viral DNA in CSF.

RESULTS

The increased antibody index of VZV and herpes simplex virus (HSV) in the CSF suggested intrathecal synthesis of IgG antibodies to these viruses. VZV-DNA was detected in the CSF by nested PCR, but neither HSV-1 nor HSV-2 DNA was detected in CSF. He was successfully treated with acyclovir and prednisolone.

CONCLUSION

PCR may be a useful tool for the diagnosis of VZV myelopathy.

Exertional rhabdomyolysis as a result of strenuous military training

We reviewed biochemical data from 19 soldiers who marched intermittently over 4 weeks, carrying about 45 kg of kit, with a limited intake of food and water. The mean serum creatine kinase activity was higher after the march (p < 0.01), although the subjects did not develop symptomatic rhabdomyolysis. The mean serum potassium level (p < 0.005) and the mean serum sodium level (p < 0.05) were lower after the march. The level of serum osmolality showed no significant changes. Subclinical rhabdomyolysis was not rare among the soldiers. We also report a case of the soldier with exertional clinical rhabdomyolysis.

[A case of rhabdomyolysis complicated with myocardial injury]

A 22-year-old man developed transient unconsciousness during running. He developed fever, nausea, vomiting, diarrhea and general fatigue. Next day, he was admitted to National Hospital Nayoro because of high serum CK level of 13,610U/l. Biochemical analyses revealed elevated serum myoglobin, increased CK-MM isozyme, aldolase and lactate dehydrogenase, increased serum osmolality, increased uric acid, and decreased serum potassium levels. Therefore, he was diagnosed as having rhabdomyolysis. In addition, serum CK-MB isozyme, cardiac myosin light chain I and troponin T were increased, suggesting the damage of cardiac muscle. Electrocardiogram showed elevated ST segment and inverted T on V2-4, which were not observed previously. He had no preceding infectious disease, drug ingestion or an underlying metabolic disorder. The rhabdomyolysis may be precipitated by the superimposition of dehydration and loss of potassium due to diarrhea and vomiting. The myocardial injury, probably produced by transient myocardial ischemia, should be paid attention in case of rhabdomyolysis.

Comparison of 5-hydroxytryptamine-induced contraction of rat pulmonary artery to that of aorta in vitro

We investigated the nature of the contraction produced by 5-hydroxytryptamine (5-HT) in the rat pulmonary artery, and compared it with that produced in the rat aorta. Both ketanserin and ritanserin inhibited 5-HT-induced contraction in the pulmonary artery non-competitively. In contrast, ketanserin competitively antagonized the contraction in the aorta. Bunazosin, a selective alpha 1-blocker, partially inhibited 5-HT-induced contraction in the pulmonary artery, but not in the aorta. In both the pulmonary artery and aorta, 8-OH-DPAT, a 5-HT1A selective agonist, produced a concentration-dependent contraction. In the pulmonary artery, 5-HT and 8-OH-DPAT produced contractions with similar potencies. In contrast, 8-OH-DPAT was less potent than 5-HT in the aorta. Bunazosin inhibited 8-OH-DPAT-induced contraction in both vessels. However, pindolol, a 5-HT1A antagonist, did not inhibit 8-OH-DPAT-induced contraction in the pulmonary artery. These results suggest that 5-HT produces contraction via not only 5-HT2 receptor, but also non-5-HT2 receptor (probably alpha 1-adrenoceptor) in the rat pulmonary artery. Furthermore, 8-OH-DPAT does not activate the 5-HT1A receptor to produce a contraction, but does activate other receptors which interact with alpha 1-adrenoceptor.

Transforming growth factor-beta 1 proliferated vascular smooth muscle cells from spontaneously hypertensive rats

To clarify whether the growth inhibitors, transforming growth factor-beta 1 (TGF-beta 1), heparin, and interferon-gamma (IFN-gamma) contribute to the development of vascular hypertrophy in spontaneously hypertensive rats (SHR), the growth of vascular smooth muscle cells (VSMC) was evaluated both for cell numbers over a period of 4 days, and [3H]thymidine incorporation over 24 h. Heparin and IFN-gamma inhibited the proliferation of VSMC from SHR and Wistar-Kyoto (WKY) rats. TGF-beta 1 enhanced SHR-VSMC proliferation by 16.6 +/- 8.9%; in contrast TGF-beta 1 inhibited WKY-VSMC proliferation by 60.5 +/- 7.4%. There was no difference in affinity, number of binding sites, or subtype expression of TGF-beta 1 receptor between SHR-VSMC and WKY-VSMC. This evidence suggests that the signal transduction system of TGF-beta 1 either the receptor itself or downstream signaling molecules, may be altered in SHR-VSMC versus WKY-VSMC. This abnormal responsiveness to TGF-beta 1 is involved in the proliferative characteristics of SHR-VSMC. Therefore, TGF-beta 1 could contribute to the development of hypertension or vascular hypertrophy in SHR.

Intraventricular changes in the beta-adrenoceptor-adenylate cyclase system of the rat heart with the progress of monocrotaline-induced right ventricular hypertrophy

We investigated the changes in the membranous beta-adrenoceptor-adenylate cyclase system in the right ventricle, left ventricle and interventricular septum during the progress of monocrotaline-induced right ventricular hypertrophy and failure. The beta-adrenoceptor density was decreased in hypertrophied right ventricle 2 to 4 weeks after treatment. When the rats showed symptoms of right ventricular failure 4 weeks after treatment, the beta-adrenoceptor density was decreased in the interventricular septum. Both basal and forskolin-stimulated adenylate cyclase activities were decreased in the right ventricle at 3 and 4 weeks, and in the interventricular septum at 4 weeks, after treatment, which indicates that the catalytic activity of adenylate cyclase is reduced. Changes in isoproterenol plus Gpp (NH) p- or sodium fluoride-stimulated adenylate cyclase activity were generally similar to those in basal activity. These data indicate that a chamber-specific decrease in beta-adrenoceptor density begins in the early stages of right ventricular hypertrophy, and that beta-adrenoceptor density and adenylate cyclase activity in the interventricular septum are decreased in the advanced stages of heart failure in monocrotaline-treated rats.

Changes in type VI adenylyl cyclase isoform expression correlate with a decreased capacity for cAMP generation in the aging ventricle

We investigated the developmental regulation of the beta-adrenergic receptor-Gs-adenylyl cyclase pathway in myocardial membranes from fetal, neonatal, adult, and mature adult rats by measuring the density of the beta-adrenergic receptor and the activities of the stimulatory guanine nucleotide-binding protein Gs and the adenylyl cyclase enzyme. Total beta-adrenergic receptor content (in femtomoles per milligram protein) was greatest in the fetal (124.4 +/- 20.5 fmol/mg) and neonatal (122.3 +/- 16.1 fmol/mg) stages and gradually decreased in the adult (90.9 +/- 8.0 fmol/mg) and mature adult (70.0 +/- 9.6 fmol/mg) stages. An equivalent pattern was seen for adenylyl cyclase activity: the basal activity of the effector enzyme or that measured in the presence of 0.1 mmol/L isoproterenol with 0.1 mmol/L Gpp(NH)p, 10 mmol/L NaF, or 0.05 mmol/L forskolin was greater in the fetus and the neonate than in the adult and the mature adult. These data suggested that decreased stimulation of the catalytic unit by Gs could be the underlying cause of diminished adenylyl cyclase activity with aging. However, quantification of Gs by reconstitution into S49 cyc- membranes (in picomoles cAMP per microgram for 10 minutes) demonstrated no significant decrease during development from fetus (1.55 +/- 0.1 pmol/microgram) to neonate (1.9 +/- 0.5 pmol/microgram) and subsequent aging to adult (2.6 +/- 0.2 pmol/micrograms) and mature adult (1.9 +/- 0.2 pmol/microgram). When Northern blot analysis was used to characterize the relative amounts of mRNA coding for Gs alpha, no significant differences were seen among the developmental stages studied.(ABSTRACT TRUNCATED AT 250 WORDS)

Absence of antioxidant effects of nifedipine and diltiazem on myocardial membrane lipid peroxidation in contrast with those of nisoldipine and propranolol

Both the production of active oxygen species and cellular damage due to concurrent lipid peroxidation are believed to be important factors in the pathogenesis of cardiovascular diseases and the ageing process. Since cardiovascular drugs are often administered over a long term, it might be advantageous if they reduced lipid peroxidation. There have been conflicting reports concerning the antiperoxidant effect of nifedipine. Therefore, we investigated whether nifedipine could inhibit lipid peroxidation in a nonenzymatic active oxygen-generating system, utilizing rat crude myocardial membranes, and compared its effect with those of propranolol, nisoldipine, and diltiazem. Nifedipine and diltiazem had no inhibitory effects on the lipid peroxidation of myocardial membranes. In contrast, nisoldipine and propranolol had a concentration-dependent antiperoxidant effect, with IC50 values of 28.2 and 50.1 microM, respectively. In addition, nisoldipine appeared to possess dual antiperoxidant mechanisms, involving both preventive and chain-breaking properties.

A case report of isolated levocardia without intracardiac anomalies associated with sick sinus syndrome

A 42-year-old female with cardiomegaly showed bradycardia without syncope. Clinical data showed that she had an isolated levocardia with interruption of the inferior vena cava. Isolated levocardia was defined as a normally placed heart associated with situs ambiguus of other viscera. She did not have intracardiac anomalies. Isolated levocardia without intracardiac anomalies, as in this case, has only been reported in 13 other cases. Isolated levocardia is often accompanied by severe complex intracardiac anomalies and, therefore, most of the patients have a short life span. Situs ambiguus, especially left isomerism, is frequently associated with deteriorated sinus node function, and an interruption of the inferior vena cava may also be an indication of this phenomenon. Therefore, the patient's sinus node function was examined using an electrophysiological study and a 24-hour ambulatory electrocardiogram. Sick sinus syndrome was finally confirmed.

Role of endothelium in biphasic hypoxic response of the isolated pulmonary artery in the rat

We investigated the roles of the endothelium in the hypoxic responses of the isolated main pulmonary artery (PA) in the rat. Hypoxia was induced by gassing an organ chamber with 95% N2 + 5% CO2 (PO2 = 34.6 +/- 3.1 Torr) instead of 16% O2 + 5% CO2 + balance N2 (PO2 = 92.8 +/- 3.0 Torr). Vascular rings were precontracted with 2 x 10(-8) M phenylephrine. A transient hypoxic contraction and a subsequent relaxation were observed in the endothelium-intact rings. The hypoxic contraction was reduced in the endothelium-denuded rings. In contrast, there were no significant differences between the hypoxic relaxation in the endothelium-intact and endothelium-denuded rings. Inhibitors of endothelium-derived relaxing factor (EDRF) activity, 2 x 10(-6) M NG-monomethyl-L-arginine (L-NMMA) and 10(-6) M methylene blue, produced 53% and 66% reductions in hypoxic contraction, respectively, Furthermore, the amount of cyclic GMP in the endothelium-intact PA rings which had been precontracted with phenylephrine decreased from 2.10 +/- 0.45 pmol/mg protein during normoxia to 0.90 +/- 0.18 pmol/mg protein during hypoxia. Indomethacin and OKY-046 did not influence hypoxic contraction or relaxation. These results suggest that hypoxic contraction of the isolated pulmonary artery in the rat is partially induced by inhibition of the release of EDRF.

Demonstration of the inner structure of a right atrial myxoma by transoesophageal echocardiography

We report a case of a large right atrial myxoma. With the use of transoesophageal echocardiography, several cysts were identified within the tumour and necrotic tissue was differentiated from myxomatous tissue according to its echo-level. Transoesophageal echocardiography was very useful for the precise diagnosis of cardiac tumour and demonstration of the inner structure.

The effect of acute hypoxia on left ventricular function with special reference to diastolic function--an analysis using ultrasonic method

In order to evaluate the effect of acute hypoxia on left ventricular (LV) contractility and diastolic function, hemodynamics and LV wall motion were investigated in anesthetized open-chest paced dogs using M-mode or pulsed Doppler echocardiography. Animals were ventilated with 10% oxygen (Hypo 1) and 6.3% oxygen (Hypo 2). LV contractility and diastolic functions were enhanced under "Hypo 1" and at an early phase of "Hypo 2". However, LV functions, both systolic and diastolic, were simultaneously reduced in the presence of hypercapnic acidosis by "Hypo 2". Peak velocities of diastolic rapid filling flow (R) and atrial contraction flow (A) were increased under "Hypo 1", but showed a biphasic change (an increase and a subsequent decrease) under "Hypo 2". The ratio of A/R, known as an index of LV diastolic function, was not altered under hypoxia alone or even under hypercapnic acidosis. Even when hypoxia seems to enhance LV contractility, LV function has already begun to be depressed with a reduction of pH. This seems, however, to be compensated for by LV dilatation and increase in preload, or preservation of left atrial performance.

Site of hypoxic pulmonary vasoconstriction in pulsatile perfused canine lung lobes

To elucidate the site of hypoxic pulmonary vasoconstriction (HPV) in the dynamic lung, we studied the effect of alveolar hypoxia (0 approximately 4% O2) on excised canine lung lobes with pulsatile perfusion from artery to vein (antegrade perfusion: AP) or vein to artery (retrograde perfusion: RP), and compared responses to hypoxia with those to serotonin and histamine. In our preparation, increases in the pulmonary vascular resistance (R) resulted in a wide range of decreases in the flow wave amplitude at the lobar inflow site (FA). These decreases in FA reflected reductions in the compliance of the vasculature proximal to the main site of resistance. The FA/R ratios of serotonin were 2.29 in AP and 0.24 in RP indicating the predominant arterial constriction, those of histamine were 0.07 in AP and 1.24 in RP indicating the selective venous constriction. In contrast, the responses to hypoxia were 0.38 in AP and 0.42 in RP. These results suggest that HPV occurs not only on the arterial side but on the venous side in the dynamic lung, and the main site of HPV is located in the peripheral pulmonary vasculature, between muscular arteries and veins which are constricted by serotonin and histamine.

[Effect of potassium channel openers on hypoxic pulmonary vasoconstriction]

The ATP-sensitive potassium channel (K+ATP) has been suggested as an important mechanism for the reactivity of vascular smooth muscle. We investigated the effects of K+ channel openers (lemakalim, pinacidil) on hypoxic pulmonary vasoconstriction (HPV) and angiotensin II (Ag II) induced vasoconstriction in isolated rat lungs (Sprague-Dawley rats: 300-450 g). Ventilation with hypoxic gas (2% O2, 5% CO2) was performed for 6 min after the injection of Ag II (0.1 microgram). Isolated lungs were perfused under constant flow (0.04 ml/g/min) using 20 ml of blood from donor rat. The perfusion pressure was used as the pulmonary artery pressure. Lemakalim or pinacidil was pre-administered through the reservoir. Pretreatment with pinacidil (10(-4) M) or lemakalim (10(-5) M) inhibited the pressor response to hypoxia, but did not inhibit the response to angiotensin II. Although the effect of lemakalim on HPV was reversed by administration of glibenclamide (10(-5) M) or tolbutamide (10(-3) M), the effect of pinacidil on HPV was not influenced by either drug. These results suggest that 1) K+ channel openers (lemakalim and pinacidil) inhibit the pressor response to hypoxia, and 2) lemakalim seems to act through K+ATP, whereas pinacidil may have other mechanisms of inhibition of vascular smooth muscle contraction. K+ATP may play an important role in the regulation of pulmonary vascular reactivity to hypoxia.

Time course of pulmonary vascular response to an acutely repetitive pulmonary microembolism in dogs--an analysis using pulmonary vascular impedance

To understand the mechanism leading to progressive pulmonary hypertension, we investigated the time course of vascular response to an acutely repetitive pulmonary microembolism in dogs by using pulmonary vascular impedance. In a normal state, the mean pulmonary arterial pressure (mPAP) was transiently increased by emboli, and the impedance moduli of 0 Hz (= Rin), 1.5 Hz and 3 Hz were slightly increased. A four-element electrical vascular model showed the transient increase in peripheral pulmonary vascular resistance (R2) and inertia, and reduction in compliance (C). In contrast, in a state of a slight pulmonary hypertension, mPAP was continuously increased by the same amount of emboli, and the impedance moduli of both 0 Hz and 3 Hz were significantly increased. By a four-element model, a severe increase in R2 and reduction in C were observed, and these changes continued. Therefore, although the vascular response to pulmonary microembolism basically depends on the degree of mechanical obstruction, this response is thought to be modulated by the responsiveness of pulmonary vessels at that time, which is involved in the alteration in the local characteristics of pulmonary vessels, and/or the recruitment of a new blood flow.

Prolonged period of global ischemia causes no change in the GTP-binding proteins in the isolated perfused rat heart

The response of the beta-adrenoceptor transduction system to global ischemia for 40 min was investigated in isolated working heart of rat. The enhancement of beta-adrenoceptors was not observed in the ischemic myocardium. A depression of forskolin-stimulated adenylate cyclase enzyme occurred with global ischemia, but no change in Gs or Gi2 was detected. Thus, the present in vitro ischemic heart model may not necessarily reflect the identical milieu induced by the in vivo myocardial ischemia.

[Technetium-99m-pyrophosphate myocardial scintigraphy in polymyositis--a case report]

A patient with polymyositis who had cardiac involvement underwent myocardial scan with technetium-99m-pyrophosphate. We used Activity Index for evaluating myocardial uptake of technetium-99m-pyrophosphate, which correlated with the degree of serum creatine phosphokinase elevation. Our findings indicate that these examinations may be helpful for identifying patients who have cardiac involvement and evaluating their response to the treatment with corticosteroids or immunosuppressants.

Transient pulsus alternans induced by isosorbide dinitrate: echocardiographic and hemodynamic evidence of reduced venous return--a case report

Transient pulsus alternans was induced by isosorbide dinitrate (ISDN) in a patient with postmyocarditis congestive heart failure under diuretic therapy. The severity and duration of pulsus alternans depended on the dose of ISDN. According to the echocardiographic and hemodynamic examinations, the superimposed preload reduction caused by ISDN combined with decreased blood volume owing to diuretic therapy most likely contributed to the development of pulsus alternans.

[A case of right atrial myxoma--the availability of transesophageal echocardiography in the detection of right atrial myxoma]

A 72-year-old woman had experienced palpitation and fatigue during exertion for two months and was referred to our hospital from her nearby hospital. On physical examination, a systolic murmur was heard in the left fourth intercostal space. A chest X-ray film showed cardiac enlargement (CTR 64%). An ECG showed elevated P waves in leads II, III. Transthoracic echocardiography revealed a large oval heterogeneous mass in the right atrium. Transesophageal echocardiography (TEE) revealed the right atrial mass clearly, which was attached to the atrial septum with a short wide stalk. This mass prolapsed from the right atrium into the right ventricle in diastole. And there were some cysts in the homogeneous high-echoic lesion. The chest CT and MRI also showed the mass in the right atrium. However, these images were not clear. Surgical excision of the mass was undertaken. A solid mass measuring 75 x 50 x 45 mm was attached to the fossa ovalis with a wide short stalk. There were several cysts in the mass. Pathological examination showed myxomatous tissue. In this case, TEE was the most valuable means for evaluation of the right atrial mass.

[Respiratory pathophysiology during sleep in patients with myotonic dystrophy]

Myotonic dystrophy is a genetic disorder inherited as an autosomal dominant trait. It is known to be associated with endocrine dysfunction, polar cataracts, cardiac abnormalities and other conditions. Respiratory distress constituents the principal problem in myotonic dystrophy. The author investigated postural change of respiratory function in 12 patients with myotonic dystrophy (MYD), and 7 patients with limb-girdle dystrophy (LG) and overnight polysomnography was performed on 10 patients with MYD and 5 patients with LG. The respiratory function in seated posture showed no significant difference between LG and MYD, but in patients with MYD, the vital capacity and the expiratory reserve volume in a supine posture was reduced in comparison to that during seated posture. However, the respiratory function in patients with LG was not significantly different in seated and supine postures. Also, in patients with MYD, there was a significant decrease in arterial PO2 from the seated posture to the supine posture, without a significant change in the arterial PCO2. However, in patients with LG, there was no significant change in arterial blood gas analysis parameters. It was speculated that these findings concerning respiratory function and blood gas analysis in patients with MYD were caused by the involvement of the diaphragm. In the supine posture, the diaphragm shifted to the cranial position because of the abdominal contents rising into thorax, therefore the lung volume was reduced and the ventilation-perfusion ratio deteriorated. The changes of respiratory function parameters and PaO2 were partly responsible for the hypoxemia observed during sleep in patients with MYD. Overnight polysomnography showed that 9 of the 10 patients with MYD and 1 of the 5 patients with LG presented apneas during sleep, particularly during REM, stage 1 and stage 2. Almost all apneas were central type, with a low percentage of obstructive apneas and the apnea index was 19.0/h (mean) in MYD, 6.5/h in one case of LG. These result strongly suggest that sleep apnea is of central origin, but the distinction between a central and an obstructive etiology is difficult in neuromuscular disease and particularly when a disorder of central ventilatory responsiveness is suspected. The respiratory function of MYD and LG in seated and supine postures was studied and overnight polysomnography performed. It was emphasized that it was important for the respiratory care of neuromuscular disease to consider the influence of postural changes in the respiratory function. The present series of studies revealed central sleep apnea in the patients with myotonic dystrophy.(ABSTRACT TRUNCATED AT 400 WORDS)

Ca2(+)-induced contraction and hyperreactivity of pulmonary arterial smooth muscle in monocrotaline-treated rats

The mechanism of progressive pulmonary hypertension induced by monocrotaline (MCT) remains controversial. To determine whether or not functional changes in pulmonary arterial smooth muscle contribute to the development of pulmonary hypertension, we examined the reactivity of isolated pulmonary artery segments 7, 14 and 21 days after a single subcutaneous injection of MCT. In Ca2(+)-free buffer, pulmonary arteries from MCT-treated rats contracted when CaCl2 was added without any other stimulation. The pulmonary artery exposed to MCT also exhibited hyperreactivity to KCl and 5-hydroxytryptamine. These functional changes in the pulmonary artery preceded the elevation of right ventricular systolic pressure and right ventricular hypertrophy. The contraction in response to Ca2+ suggests that the pulmonary artery of rats given MCT may be contracted in situ. Vasoconstriction due to these alterations may play an important role in the development of pulmonary hypertension according to this model.

Changes in the pulmonary vascular input impedance in patients with atrial septal defect after surgical correction

In order to evaluate whether there is pulmonary vascular disease in patients with atrial septal defect (ASD), we used the pulmonary vascular input impedance to estimate the stiffness of the pulmonary vessels with before and after surgical intervention. Ten control subjects and 11 patients with ASD (9 operable and 2 inoperable) were examined. In preoperative patients the decreased total pulmonary resistance (Rin) and pulmonary vascular resistance appeared to open new parallel vascular channels with increased blood flow. Further, there were no significant differences in the pulmonary vascular input impedance spectrum and phase, and characteristic impedance among control subjects, preoperative and postoperative patients. Although distensibility of the pulmonary vascular wall in operable patients was similar to that in control subjects, an excessive elevation in Rin and input impedance modulus was observed in inoperable patients. The results demonstrate that the normal input impedance spectrum and phase in patients with ASD is predictive of a good prognosis after successful surgical correction.

Probucol-induced QT prolongation and torsades de pointes

Probucol administration of 4 weeks produced torsades de pointes associated with exacerbated QT interval prolongation in a 36-year-old woman with Romano-Ward syndrome. With discontinuance of probucol, the QT interval corrected for rate shortened from 620 msec to 500 msec and ventricular ectopic beats disappeared completely. Although probucol is known to prolong the QT interval, associated ventricular tachyarrhythmia has not been reported in humans as yet. This case suggests that one should be very careful in the administration of probucol to patients with long baseline QT intervals.

A case of Rendu-Osler-Weber disease with cerebral hemangioma, multiple pulmonary arteriovenous fistulas and hepatic arteriovenous fistula

A 46-year-old woman was admitted to the hospital because of dyspnea and palpitation. Physical examination showed severe anemia and cardiac distress. Telangiectases were found in the conjunctivas, lips and oral mucosa. Chest roentogenogram showed an enlarged cardiac silhoutte and multiple coin lesions in both lower lung fields. We diagnosed her as Rendu-Osler-Weber disease (ROW). The angiographic studies showed hemangioma in the foramen of Monro, bilateral multiple pulmonary arteriovenous fistulas, and hepatic arteriovenous fistula with a large distortion of the proper hepatic artery. Although associated vascular dysplasias have been described in patients with ROW, there is no reports on ROW in which multiple vascular abnormalities concomitantly existed such as the present case. In 163 detailed cases of ROW in Japan, the frequency of vascular lesions was summarized, and this result showed that the vascular lesions of the lung were more frequent than that of the liver or brain, in comparison with countries in Europe and America. It is very important for diagnosis and its prognosis to perform a detailed angiographic examinations and to demonstrate the precise sites of the vascular dysplasias in patients with ROW.

[Obstructive sleep apnea syndrome with reversible interventricular septal displacement during sleep: a case report]

A case of the obstructive sleep apnea syndrome revealed reversible leftward displacement of the interventricular septum by echocardiography during sleep. A 46-year-old housewife with congenital micrognathia was admitted to our hospital complaining of severe dyspnea and general edema. On admission, she had severe hypoxemia (PaO2 = 35.2 mmHg), pulmonary hypertension (mean pulmonary artery pressure = 70 mmHg) and right heart failure. Her echocardiograms revealed enlargement of the right ventricle with a flattened left ventricle. A sleep study performed after partial resolution of her right heart failure disclosed that severe hypoxemia and pulmonary hypertension (mean pulmonary artery pressure = 70 mmHg) occurred after relatively long periods of apnea. With vigorous inspiratory efforts during sleep apnea, transient enlargement of the right ventricle and leftward displacement of the septum causing the flattened left ventricle were observed echocardiographically. A concomitant decrease in left ventricular inflow velocities was also observed by the pulsed Doppler method. However, these findings immediately returned to normal with the resumption of ventilation. We concluded that these repetitive apneic events due to obstruction of the airway during sleep might accelerate complete eventual pulmonary hypertension and right heart failure.