A Case of 17α-hydroxylase/17,20-lyase Deficiency Diagnosed at 45 Years of Age with Hyperaldosteronism

17α-hydroxylase deficiency is a type of congenital adrenocortical hyperplasia that is typically diagnosed in childhood or adolescence. It manifests as hypertension with gonadal dysfunction as the primary symptom. We herein report 17α-hydroxylase/17,20-lyase deficiency (17OHD) diagnosed at the age of 45 years. The patient presented with hypertension, irregular menstruation, and hyperaldosteronism. The clinical manifestations of 17OHD vary based on the specific variant pattern of CYP17A1. In this case, the variant was c.157_159 TCC del p. Phe53del, which has been frequently reported in Japan. The enzymatic deficiency due to this variant is partial, leading to a delay in making a correct diagnosis.

Pilot Evaluation of Possible Airborne Transmission in a Geriatric Care Facility Using Carbon Dioxide Tracer Gas: Case Study

BACKGROUND

Although several COVID-19 outbreaks have occurred in older adult care facilities throughout Japan, no field studies focusing on airborne infections within these settings have been reported. Countermeasures against airborne infection not only consider the air change rate (ACR) in a room but also the airflow in and between rooms. However, a specific method has not yet been established by Japanese public health centers or infectious disease-related organizations.

OBJECTIVE

In April 2021, 59 COVID-19 cases were reported in an older adult care facility in Miyagi, Japan, and airborne transmission was suspected. The objective of this study was to simultaneously reproduce the ACR and aerosol advection in this facility using the carbon dioxide (CO₂) tracer gas method to elucidate the specific location and cause of the outbreak. These findings will guide our recommendations to the facility to prevent recurrence.

METHODS

In August 2021, CO₂ sensors were placed in 5 rooms where airborne infection was suspected, and the CO₂ concentration was intentionally increased using dry ice, which was subsequently removed. The ACR was then estimated by applying the Seidel equation to the time-series changes in the CO₂ concentration due to ventilation. By installing multiple sensors outside the room, advection outside the room was monitored simultaneously. Aerosol advection was verified using computer simulations. Although the windows were closed at the time of the outbreak, we conducted experiments under open-window conditions to quantify the effects of window opening.

RESULTS

The ACR values at the time of the outbreak were estimated to be 2.0 to 6.8 h^-1 in the rooms of the facility. A low-cost intervention of opening windows improved the ventilation frequency by a factor of 2.2 to 5.7. Ventilation depended significantly on the window-opening conditions (P values ranging from .001 to .03 for all rooms). Aerosol advection was detected from the private room to the day room in agreement with the simulation results. Considering that the individual who initiated the infection was in the private room on the day of infection, and several residents, who later became secondarily infected, were gathered in the day room, it was postulated that the infectious aerosol was transmitted by this air current.

CONCLUSIONS

The present results suggest that secondary infections can occur owing to aerosol advection driven by large-scale flow, even when the building design adheres to the ventilation guidelines established in Japan. Moreover, the CO₂ tracer gas method facilitates the visualization of areas at a high risk of airborne infection and demonstrates the effectiveness of window opening, which contributes to improved facility operations and recurrence prevention.

Retroperitoneal Paraganglioma With Asymptomatic Follicular Lymphoma: A Case Report

Paraganglioma (PGL) is a rare tumor originating from extra-adrenal paraganglionic chromaffin tissues, and most sympathetic PGLs have excessive catecholamine secretion. However, nonfunctional PGLs are sometimes found. Although malignant PGL is defined by metastasis to nonchromaffin tissues, it is difficult to predict malignancies due to the lack of reliable markers of potential malignancies. We report the case of a 69-year-old Japanese woman with an incidental retroperitoneal tumor and multiple enlarged mesenteric lymph nodes simultaneously. The patient had no subjective symptoms and there were no laboratory findings suggesting catecholamine hypersecretion. Both the retroperitoneal tumor and the enlarged mesenteric lymph nodes showed high accumulation of fluorodeoxyglucose (FDG), whereas metaiodobenzylguanidine (MIBG) was accumulated only at the retroperitoneal tumor. Although a retroperitoneal tumor was diagnosed as nonfunctional PGL by examination including MIBG scintigraphy, the cause of enlarged mesenteric lymph nodes could not be diagnosed by imaging and biochemical tests. As a result of retroperitoneal tumor resection and mesenteric lymph nodes sampling, histopathological examination revealed that a retroperitoneal tumor was PGL and enlarged mesenteric lymph nodes were follicular lymphoma. To reveal an underlying genetic factor, we performed whole exome sequencing of genomic DNA, and we identified 2 possible candidate variants in SDHD and DLST, but the pathogenicity of these variants remains uncertain in the present case. This rare case reinforces the importance of histopathological diagnosis of nonchromaffin tissue lesions in patients with PGL for the appropriate treatment strategy.

Decision tree analysis for factors associated with dental caries in school-aged children in Japan

OBJECTIVE

Our study aimed to elucidate the interactive relationship between factors associated with dental caries in school children using decision tree analysis.

RESEARCH DESIGN

Cross-sectional study Methods: Participants were recruited from public primary schools (9-12 years, 4th to 6th grade) and junior high schools (12-13 years, 1st grade) in Japan. A total of 1775 students (928 boys and 847 girls) were analyzed. Questionnaire survey, oral examination, and saliva test were performed. Multiple logistic regression and decision tree analysis were performed.

RESULTS

Multiple logistic regression showed an association between dental caries and toothpaste use, dental attendance and the presence of Streptococcus mutans. Decision tree analysis showed that students with non-regular dental attendance were at a significantly higher risk of dental caries at the late stage of primary school. At the early stage of primary school, high levels of Streptococcus mutans and male sex were factors associated with dental caries. In students with low levels of Streptococcus mutans, using toothpaste occasionally was associated with a high risk of dental caries.

CONCLUSIONS

In early primary school years, S. mutans may be a useful screening and diagnostic tool for dental caries. In students with high levels of S. mutans, sex may be associated with dental caries. Furthermore, in students with low levels of S. mutans, regular use of toothpaste should be encouraged, and in late primary school years, regular dental attendance should be encouraged to prevent dental caries.

Unilateral recurrent laryngeal nerve neuropraxia following placement of a ProSeal laryngeal mask airway in a patient with CREST syndrome

We report a severe unilateral recurrent laryngeal nerve neuropraxia following use of the ProSeal laryngeal mask airway (PLMA) in a 71-year-old female patient with CREST syndrome. She required amputation of the 5th phalanx of foot because of gangrene due to Raynaud's syndrome. Anesthesia was induced with propofol, and a size 3 PLMA was inserted. Anesthesia was maintained with sevoflurane and nitrous oxide for 2 h and the operation was performed uneventfully. On removal of PLMA, the cuff volume was measured to 40 ml. The patient did not complain of respiratory discomfort shortly after PLMA removal. However, the next day she developed dysphagia and hoarseness. Laryngoscopic examination revealed unilateral vocal cord paralysis. Cricothyrotomy was required because of suspected silent aspiration pneumonia. The pharyngolaryngeal complications improved with a mobile vocal cord but slight hoarseness after 2 months. We considered the patient's CREST syndrome with a potential of tissue ischemia, and the high intracuff pressure of the PLMA due to nitrous oxide influx, to be the cause of severe recurrent laryngeal nerve neuropraxia in this case.

Hypergravity modulates behavioral nociceptive responses in rats

Hypergravity (2G) exposure elevated the nociceptive threshold (pain suppression) concomitantly with evoked neuronal activity in the hypothalamus. Young Wistar male rats were exposed to 2G by centrifugal rotation for 10 min. Before and after 2G exposure, the nociceptive threshold was measured as the withdrawal reflex by using the von Frey type needle at a total of 8 sites of each rat (nose, four quarters, upper and lower back, tail), and then rats were sacrificed. Fos expression was examined immunohistochemically in the hypothalamic slices of the 2G-treated rats. When rats were exposed to 2G hypergravity, the nociceptive threshold was significantly elevated to approximately 150 to 250% of the 1G baseline control levels in all the examination sites. The 2G hypergravity remarkably induced Fos expression in the paraventricular and arcuate nuclei of the hypothalamus. The analgesic effects of 2G hypergravity were attenuated by naloxone pretreatment. Data indicate that hypergravity induces analgesic effects in rats, mediated through hypothalamic neuronal activity in the endogenous opioid system and hypothalamo-pituitary-adrenal axis.

Gravity stress elevates the nociceptive threshold level with immunohistochemical changes in the rat brain

Young Wistar male rats were exposed to 2G hypergravity by continuous centrifugation for 15 minutes. The nociceptive threshold was measured by using the von Frey type filament on the rat skin surfaces after hypergravity exposure. Following the hypergravity exposure, rats were sacrificed with anesthesia, then perfused and fixed for immunohistochemical examination. The 2G hypergravity elevated the nociceptive threshold up to 2-fold and induced analgesic effects on rats that remained for 2 hours after termination of centrifugation. Expression of Fos-immunoreactive proteins was prominently induced by 2G hypergravity in the arcuate nucleus and the paraventricular nucleus of the hypothalamus. The 15-minute flash exposure to 2G hypergravity induced pain suppression in rats, which might be attributed to change of neuronal activity in rat hypothalamus.

Hypergravity and opioid-mediated pain suppression in rats

It is known that pain suppression in animals is induced by certain environmental stimulus. However, little is known about the effects of gravitational alteration on the nociceptive responses in rats. A recent study indicated that Fos protein expression was strongly induced in the vestibular-related brainstem regions of rats that were exposed to 2 G hypergravity (Gustave Dit Duflo et al., 2000). A number of studies indicate that Fos expression is induced in the brain by various kinds of stress. We showed that either long-term exposure or short-term exposure to 2 G hypergravity elevated the nociceptive threshold in the rat skin surfaces, in concomitant with Fos induction in the hypothalamus including the arcuate nucleus and paraventricular nucleus (Kumei et al., 2000). We have examined the possible involvement of beta-endorphin, an endogenous opioid, in the hypergravity-induced analgesic effects on rats and its counteraction by naloxone, an opioid receptor antagonist.

Determination of reduced, protein-unbound, and total concentrations of N-acetyl-L-cysteine and L-cysteine in rat plasma by postcolumn ligand substitution high-performance liquid chromatography

A high-performance liquid chromatographic assay was developed for the quantitative determination of the sulfur-containing amino acids N-acetyl-L-cysteine (NAC) and L-cysteine (Cys) in rat plasma. The thiols were separated by reverse-phase ion-pair chromatography, and the column eluent was continuously mixed with an iodoplatinate-containing solution. The substitution of sulfur of the thiol compound with iodide was quantitatively determined by measuring changes in the absorption at 500 nm. The low-molecular-weight disulfides and mixed disulfide conjugates of thiols with proteins were entirely reduced to the original reduced compounds by dithiothreitol. By reducing these two types of disulfides separately during sample pretreatment, the reduced, protein-unbound, and total thiol concentrations could also be determined. Validation testing was performed, and no problems were encountered. The limit of detection was approximately 20 pmol of thiol on the column. The present method was used to measure the plasma concentrations of NAC and Cys in the rat after a bolus intravenous administration of NAC, focusing on disulfide formation. The binding of NAC to protein through mixed disulfide formation proceeds in a time-dependent and reversible manner. Moreover, this "stable" covalent binding might limit total drug elimination, while the unbound NAC is rapidly eliminated. Consequently, the analytical method described in this study is very useful for the determination of plasma NAC and Cys, including disulfide conjugates derived from them.

Flumazenil abolishes midazolam-induced increase in the work of nasal breathing

PURPOSE

To evaluate the effects of midazolam sedation followed by flumazenil antagonism on the work of nasal breathing in normal humans.

METHODS

We measured minute ventilation through the nasal route, respiratory frequency, nasal resistance (Rn) and the work of nasal breathing under three conditions: awake, during midazolam sedation, and after flumazenil antagonism in eight healthy human subjects. A custom-made, partitioned face mask enabled nasal and oral airflow to be measured separately. To calculate Rn and the work of nasal breathing, nasal mask and oropharyngeal pressure was also measured.

RESULTS

Total resistive work spent on the upstream segment of the nasal route per minute (Wn) (J x min(-1)) was greater during midazolam sedation (3.6 +/- 2.9) than while awake (1.6 +/- 0.9) and after flumazenil antagonism (1.7 +/- 0.6), respectively (mean +/- SD) (P < 0.05). Total resistive work spent on the upstream segment of nasal breathing (WnNnE) (JxL(-1)) increased from 0.31 +/- 0.14 to 0.75 +/- 0.61 after midazolam administration (P < 0.05) and decreased to 0.31 +/- 0.10 after flumazenil. Following midazolam administration, a strong correlation was observed between changes in WnNnE and changes in Rn r = 0.852, P < 0.0001), whereas there was no correlation between changes in Wn and changes in Rn r = 0.159, P = 0.279).

CONCLUSION

The work of breathing spent on the upstream segment of the nasal route increases during midazolam sedation and returns to baseline after flumazenil antagonism.

Nociceptive responses and immunohistochemical changes in the rat brain under gravity stress

It is well known that exposure to various stresses leads to pain suppression in animals. However, there is no report about the effects of gravitational alteration to serve as a kind of stress. The purpose of the present study is to clarify the effect of hypergravity (2 G) on the nociceptive responses and histochemical changes in rats. We examined the level of the threshold of withdrawal reflex against the noxious [correction of noxicious] stimulation in rats that were exposed to 2 G. Data show that the 2 G exposure elevates the nociceptive threshold. We have demonstrated for the first time that gravity change induces analgesic effects on rats in concomitant with c-fos induction in the arcuate, and paraventricular nuclei of rat hypothalamus. Gravity change acts as a kind of stress in rats.

Water extract of defatted rice bran suppresses visceral fat accumulation in rats

Rice bran has been reported to inhibit pancreatic lipase activity in vitro. This action shows that administration of rice bran may result in a decrease in plasma triglyceride levels and suppress accumulation of fat in vivo. We administered water extract of defatted rice bran (WED-rice bran) to rats to determine its effects. Single administration of WED-rice bran at a dose of 1 g/kg body weight caused a decrease in plasma triglyceride levels in fat emulsion induced hypertriglyceridemic rats. Four week administration of WED-rice bran suppressed accumulation of visceral fat and body weight gain without influencing food consumption, liver function, and renal function. These results indicate that a reduction of plasma triglycerides and suppression of visceral fat accumulation may be induced by pancreatic lipase inhibition caused by administration of WED-rice bran.

Advancement of the mandible facilitates nasal breathing in human subjects sedated with midazolam

PURPOSE

To determine how anterior advancement of the mandible (ADM) affects spontaneous breathing through the nasal route in healthy human volunteers sedated with intravenous midazolam.

METHODS

In four subjects who exhibited nasal breathing during midazolam sedation (intravenous dose: 0.09+/-0.02 mg x kg(-1), mean +/- SD), we measured respiratory rate (RR), peak nasal inspiratory airflow rate (V(nIpeak)) peak nasal expiratory airflow rate (V(nEpeak), duty ratio (Ti/Ttot) and nasal resistance (Rn) before and after ADM. Nasal resistance was calculated by dividing the difference between nasal mask and oropharyngeal pressure by airflow rate at peak nasal inspiratory airflow.

RESULTS

The RR, V(nIpeak), and V(nEpeak) increased following ADM (P<0.001, respectively). On the contrary, Ti/Ttot decreased after ADM (P<0.001). Consequently, ADM decreased Rn from 30.4+/-40.8 to 5.0+/-5.6 (cm H2O x l(-1) x sec(-1)) (mean +/- SD) (P<0.001). In these four subjects, no respiratory airflow was observed through the oral route before and after ADM.

CONCLUSION

Advancement of the mandible decreases nasal resistance, thereby facilitating spontaneous breathing through the nasal route in normal humans sedated with midazolam.

Experimental infusion phlebitis: tolerance pH of peripheral vein

This study aims to determine the pH that peripheral veins can tolerate. Intravenous nutrient solutions with different pHs (from 4.52 to 6.71) were infused into rabbit ear veins, and the veins were examined histopathologically. After 6-hr infusion at 10 mL/kg/hr, a commercial 2.72% amino acid/7.5% glucose solution with electrolytes (AG) caused obvious phlebitic changes, such as loss of venous endothelial cells, inflammatory cell infiltration, and perivascular edema, in all 6 rabbits because of its low pH (4.52) and high titratable acidity (22 mEq/L). The phlebitis was reduced when the solution was neutralized with NaOH to pH 5.93, and was almost eliminated when the pH was neutralized to 6.49. After 8-hr infusion at 15 mL/kg/hr, AG-adjusted pH to 6.30 caused slight phlebitic changes, but AG-adjusted pH to 6.71 scarcely caused any change. Furthermore, 24-hr infusion of the pH 6.49 solution caused no histopathological changes in 3 rabbits. These results suggest that the tolerance pH for the peripheral vein is about 6.5, and that an infusion solution does not cause phlebitis due to acidity if the pH is not lower than the tolerance pH.

The effect of Lipo prostaglandin E1 on cauda equina blood flow in patients with lumbar spinal canal stenosis: myeloscopic observation

STUDY DESIGN

Myeloscopic examination was performed to observe the cauda equina in patients with lumbar spinal canal stenosis before and after treatment with Lipo prostaglandin E1, a strong peripheral vasodilator.

OBJECTIVES

The purpose of this study was to clarify the effects of Lipo prostaglandin E1 on blood flow in the cauda equina in patients with lumbar spinal canal stenosis.

SETTING

Japan, Kagoshima

METHODS

We performed myeloscopic observations of morphological changes in blood vessels running along the cauda equina in 11 patients with lumbar spinal canal stenosis before and after treatment with Lipo prostaglandin E1.

RESULTS

In six of these patients, dilation of the running blood vessels was observed immediately after administration. In all of the patients who exhibited a dilation of vessels on the surface of the cauda equina, intermittent claudication and lower extremity pain and/or numbness lessened immediately after examination. However, none of the patients who exhibited no morphological changes in the vessels along the cauda equina after administration of Lipo prostaglandin E1 experienced any improvement of symptoms at the time of examination.

CONCLUSION

Results of this study suggest that Lipo prostaglandin E1 may enhance blood flow in the cauda equina and improve clinical symptoms in some patients with lumbar spinal stenosis.

Cytosolic phospholipase A2, increased and activated in the eosinophils of patients with hypereosinophilic syndrome in vivo, is involved in the augmented release of leukotriene C4

OBJECTIVE

Eosinophils from patients with hypereosinophilic syndrome (HES) showed augmented release of leukotriene C4 (LTC4) by stimulation with A23187. In the present study, we investigated the involvement of cytosolic phospholipase A2 (cPLA2) in this phenomenon.

METHODS

Eosinophils from normal and HES donors (2.5 x 10(6) cells/ml) were incubated with A23187 (0.03-3 microM) for 60 min in the presence or absence of a cPLA2 inhibitor, AACOCF3. The LTC4 released from eosinophils was measured by enzyme immunoassay. Distribution of cPLA2 and 5-lipoxygenase (5-LO) proteins within the eosinophils were detected by Western immunoblotting.

RESULTS

The level of LTC4 released from the HES eosinophils by stimulation with A23187 was higher than that from normal eosinophils. The A23187-induced LTC4 release was inhibited by AACOCF3 in a dose-dependent manner. The amounts of cPLA2 seemed to be increased in the non-stimulated HES eosinophils by an analysis of immunoblotting. To be noticed was that cPLA2 was detected as a phosphorylated and membrane-bound form in the HES eosinophils, but not in the normal eosinophils. In contrast, localization of 5-LO within the eosinophils under A23187 stimulation was not different between normal and HES donors, while the amounts of 5-LO also seemed to be increased in the HES eosinophils.

CONCLUSIONS

These results suggest that cPLA2, increased and activated (phosphorylated and membrane-translocated) in vivo, is involved in the augmented release of LTC4 from the HES eosinophils.

Antibodies against type II phospholipase A2 prevent renal injury due to ischemia and reperfusion in rats

This study was performed to determine the involvement of type II phospholipase A2 (PLA2-II) in renal injury caused by ischemia and reperfusion. Ischemia and reperfusion significantly elevated levels of blood urea nitrogen and serum creatinine in rats. These increases were significantly reduced by i.v. administration of rabbit IgG F(ab')2 fragments against rat PLA2-II. Increased levels of acid-stable PLA2 activity in the kidney were caused by ischemia and reperfusion, and were suppressed by administration of anti-PLA2-II F(ab')2. Increased levels of myeloperoxidase activity, a marker of neutrophil infiltration, in the kidney were also reduced after anti-PLA2-II F(ab')2 treatment. These results suggest that PLA2-II plays a pivotal role in pathogenesis of ischemia and reperfusion injury through induction of neutrophil infiltration.

Effects of long-term ursodeoxycholate administration on expression levels of secretory low-molecular-weight phospholipases A2 and mucin genes in gallbladders and biliary composition in patients with multiple cholesterol stones

Group IIA phospholipase A2 (PLA2), a secretory low-molecular-weight PLA2, may play a critical role in the process of gallbladder mucosal inflammation in multiple cholesterol stones, which in turn may produce biliary pronucleating proteins as well as mucin. On the other hand, ursodeoxycholate (UDC) decreases biliary levels of various pronucleating proteins, possibly because of its membrane-protective effects on the inflamed gallbladder mucosa. To elucidate that beneficial effect of UDC, the expression levels of low-molecular-weight PLA2s, group IIA PLA2 (PLA2-IIA), and group V PLA2 (PLA2-V), and mucin core polypeptide genes in the gallbladders were studied for UDC-treated patients and untreated patients with multiple cholesterol stones. Furthermore, the results were correlated with alterations in biliary composition. With long-term administration of UDC, the PLA2-IIA protein mass (2.7 +/- 0.5 vs. 5.0 +/- 0.4 ng/mg x protein [mean +/- SEM]; P < .01) and steady-state mRNA level, as well as the PLA2-V mRNA level, were significantly decreased in the gallbladders, where the prostaglandin E2 (PGE2) level was concomitantly decreased (190.7 +/- 27.9 vs. 393.6 +/- 55.3 pg/mg x protein; P < .01). In the gallbladder bile, the immunoradiometrically determined PLA2-IIA levels were significantly decreased in the UDC-treated patients (43 +/- 4 ng/dL; P < .01) in comparison with untreated patients (78 +/- 6 ng/dL). Significant decreases were similarly found for total protein, mucin, and free arachidonate concentrations, as well as nucleation activity in the bile. The degree of the changes was found to be rather small in solitary stones. In contrast to the decreased mucin concentration, however, there were no significant changes in the expression levels of mucin core polypeptide genes (MUC1-MUC6) between the UDC-treated and untreated patients. Long-term UDC administration was observed to lower the increased PLA2-IIA protein mass and mRNA level, as well as the PLA2-V mRNA level, in the gallbladders of patients with multiple cholesterol stones, which in turn may be of therapeutic importance in improving the gallbladder mucosal inflammation. Effects of UDC on secretory low-molecular-weight PLA2s as inflammatory mediators may relate to the reported efficacy of UDC treatment in cholesterol gallstone disease.

Synergistic effect of type II phospholipase A2 and platelet-activating factor on Mac-1 surface expression and exocytosis of gelatinase granules in human neutrophils: evidence for the 5-lipoxygenase-dependent mechanism

Stimulation of human neutrophils with inflammatory mediators such as TNF-alpha or platelet-activating factor (PAF) induces translocation of adhesion molecule Mac-1 (CD11b/CD18) from secretory vesicles to the plasma membrane. Type II phospholipase A2 (PLA2-II) also induces translocation of Mac-1 from secretory vesicles. However, there are more Mac-1 molecules in gelatinase granules and specific granules than in secretory vesicles. Therefore, different combinations of PLA2-II and other mediators were examined for their ability to induce gelatinase granules and specific granules to induce Mac-1 surface expression. The combination of PLA2-II and PAF synergistically increased Mac-1 surface expression, and the effect was greater than the combinations of PLA2-II with TNF-alpha, IL-8, or FMLP. Additionally, the combination of PLA2-II and PAF induced exocytosis of both secretory vesicles and gelatinase granules, which did not occur with either PLA2-II alone or PAF alone. The induction was accompanied by marked production of leukotriene B4. AA861, an inhibitor of 5-lipoxygenase, did not inhibit exocytosis of secretory vesicles but did inhibit exocytosis of gelatinase granules and decrease Mac-1 surface expression. It was also found that Ca2+ influx is essential for 5-lipoxygenase activation, because Ni2+, which blocks the influx of extracellular Ca2+, inhibited the production of leukotriene B4. These results suggest that stimulation by the combination of PLA2-II and PAF, unlike stimulation by each mediator alone, causes exocytosis of gelatinase granules via the 5-lipoxygenase pathway, resulting in a synergistic increase in neutrophil Mac-1 surface expression during inflammatory processes.

[Guillain-Barré syndrome with nerve conduction blocks at multiple common entrapment sites that rapidly disappeared after plasmapheresis]

Nerve conduction blocks (NCBs) in Guillain-Barré syndrome (GBS) are frequently found at the distal terminals, proximal segments, and common entrapment sites of peripheral nerves. NCBs at distal terminals and proximal segments are considered to be due to vulnerability of the sites to the humoral factors of GBS because of relative blood-nerve barrier deficiencies. In contrast, it is not clear whether NCBs at common entrapment sites in GBS are due to a vulnerability to humoral influences or to direct mechanical compression injuries. We report a case of a 22-year-old man with GBS. His electrophysiologic examination revealed NCBs at multiple common entrapment sites. All conduction blocks rapidly disappeared after plasmapheresis, in parallel with clinical improvement. The patient was ambulatory throughout the clinical course, suggesting that his common entrapment sites remained free from compression injuries. Rapid improvement by plasmapheresis suggested that there were no demyelinative histologic changes in the NCB sites. Such NCBs may be caused by some humoral factor that is removed by plasmapheresis. Therefore, the common entrapment sites in our patient may have been especially vulnerable to the humoral factor of GBS.

[Familial Creutzfeldt-Jakob disease with the heterozygous point mutation at codon 200 of the prion protein gene (Glu-->Lys)--report of CJD200 brothers of Yamanashi Prefecture origin]

We report two brothers with familial Creutzfeldt Jakob disease (CJD) having a heterozygous point mutation at codon 200 of the prion protein gene (Glu-->Lys): CJD200. The brothers were born in Kitakoma-gun, Yamanashi Prefecture. Patient 1, a 62-year-old man, developed CJD in 1995 and died nine months later. Patient 2, his brother, developed CJD200 at the age of 58 in 1982 and died 13 months later. They both exhibited rapidly progressive dementia with myoclonus and periodic synchronous discharges on electroencephalograms and became bedridden with three or four months. DNA analysis of peripheral blood cells of patient I showed a point mutation in the prion protein gene at codon 200: GAG-->AAG (Glu-->Lys). Five families with CJD200, 11 patients, have been reported in Japan to date, and nine of the patients from four families were born in Yamanashi Prefecture and vicinity. Our patients were born in the same area. We suspect that there is a cluster of CJD200 in Yamanashi Prefecture and vicinity. In Europe and America the phenotype of CJD200 has been reported to be heterogeneous, whereas the clinical features in Japanese cases are fairly homogeneous. We suspect that these patients have a common ancestor with a codon 200 mutation, and that that explains why the phenotypes are homogeneous.

Human type II phospholipase A2-induced Mac-1 expression on human neutrophils

To investigate the effect of type II phospholipase A2 (PLA2-II) on neutrophil function, we assessed the Mac-1 (CD11b/CD18) expression on human neutrophils by flow cytometry after incubation of the cells with human PLA2-II. PLA2-II at a concentration of 10 microg/mL increased the Mac-1 expression by 150% compared with unstimulated cells at 30 min and after. Under these conditions PLA2-II increased the exocytosis from secretory vesicles but not from azurophilic, specific, or gelatinase granules. The results suggest that PLA2-II induces translocation of Mac-1 from the secretory vesicles to the plasma membrane. The Mac-1 induction mediated by PLA2-II was inhibited by an anti-PLA2-II antibody, which was able to inhibit the catalytic activity. However, the Mac-1 induction by PLA2-II was not inhibited by a 5-lipoxygenase, cyclooxygenase inhibitor, or a platelet-activating factor antagonist. Thus, we examined the effects of fatty acids and lysophospholipids on Mac-1 expression. Only arachidonic acid induced Mac-1 expression. These results imply that PLA2-II induces Mac-1 expression on neutrophils via production of arachidonic acid.

Myeloscopic observation of adhesive arachnoiditis in patients with lumbar spinal canal stenosis

In this study a myeloscope was used to assess the influence of adhesive arachnoiditis on the surgical outcome of patients with lumbar spinal canal stenosis (LSS). The presence or absence and the degree of the complication of adhesive arachnoiditis were preoperatively determined by myeloscopy in 36 patients with LSS, and these findings were compared with the postoperative results. Various degrees of adhesive changes in the cauda equina were observed in all 36 patients. Patients with marked adhesions, which may indicate a blocked cauda equina, had distinctly worse operative results than did patients with slight or moderate adhesions. Adhesive arachnoiditis was considered to be one of the causes for the poor operative results for LSS. Myeloscopy is useful in diagnosing the morbid condition of the cauda equina in LSS, and for predicting the operative results.

Indication of fusion for lumbar spinal stenosis in elderly patients and its significance

STUDY DESIGN

Selection of surgical therapy for lumbar canal stenosis in elderly patients is discussed. Decompression alone and decompression with fusion were evaluated.

OBJECTIVES

To determine the indication of decompression with fusion for lumbar spinal stenosis in elderly patients.

SUMMARY OF BACKGROUND DATA

Although there is no objection to posterior decompression, which is regarded as the first choice of surgical therapy for lumbar spinal stenosis in the elderly, it is debatable whether or not fusion should be used with decompression.

METHODS

The presence or absence of instability was defined by Posner's method from preoperative plain radiographic lateral findings. Thirty-four elderly patients with lumbar canal stenosis were studied. Seventeen of the 34 patients were found to have instability. Ten of the 17 patients with spinal instability underwent decompression and instrumented fusion. The seven remaining patients with spinal instability underwent decompression alone. The 17 patients without spinal instability were treated by decompression alone. Preoperative symptoms, postoperative results, and changes in radiographic findings were compared among the three groups.

RESULTS

The group treated by decompression and fusion showed the best results. The group treated by decompression in the presence of instability showed the worst results by the Japanese Orthopaedic Association back scores. Good results can be obtained by decompression alone only if the patients do not have instability as defined by Posner.

CONCLUSIONS

The definition of instability by Posner's method proved useful for selecting elderly patients with instability for fusion treatment. Fusion with instrumentation should be performed on elderly patients with instability after decompression.

Preparation and characterization of human rheumatoid arthritic synovial fluid phospholipase A2 produced by recombinant baculovirus-infected insect cells

We prepared human rheumatoid arthritic synovial fluid phospholipase A2 (PLA2) [EC 3.1.1.4] from insect cells infected with a recombinant baculovirus. The PLA2 DNA was designed, changing the original codons to those used frequently in the polyhedrin gene. Sixteen oligo-deoxynucleotides ranging from 40 to 70 nucleotides were chemically synthesized and then assembled to form the whole PLA2 gene. The gene thus synthesized was then placed under the control of the polyhedrin promoter of Autographa californica nuclear polyhedrosis virus. The recombinant virus was infected into Spodoptera frugiperda cells. The infected cells secreted protein having PLA2 activity into the culture medium. The enzyme level in the medium reached about 3 mg/liter on day 4 after infection. The secreted protein was purified to a single band of 14,000 Da on SDS-PAGE, by means of cation exchange chromatography and reverse-phase HPLC. N-terminal amino acid sequence analysis revealed that the recombinant protein was recognized and cleaved at the signal sequence in the insect cell. The purified enzyme had almost the same specific enzyme activity, substrate specificity, pH optimum, Ca2+ ion dependency, and kinetic values as those of the natural enzyme.

[An autopsied case of intravascular malignant lymphomatosis with paraparesis, that presented a leukoencephalopathy-like image after spinal cord biopsy]

A 54-year-old woman was hospitalized because of paraparesis, sensory disturbance of the lower extremities, and dysuria. Laboratory data included an erythrocyte sedimentation rate (ESR) of 16 mm/h and lactate dehydrogenase (LDH) level of 459 IU/l. Myelogram showed an enlarged spinal cord at the L1 level, and spinal MRI revealed a high signal area on T2-weighted images. Spinal cord biopsy by thoraco-lumbar laminectomy showed thickening of the pia mater and neovascularization, but no malignant cells. Immediately after the operation, the patient displayed progressive mental deterioration. Cranial MRI showed widespread high signal areas in the cerebral white matter on T2-weighted images which resembled those of leukoencephalopathy. Steroid therapy was tried but was ineffective. Ten months after the onset of symptoms, a brief period of regression of both clinical symptoms and MRI appearances occurred following the administration of Inosiplex, subsequent progressive deterioration led to death 14 months after the onset of symptoms. LDH, C-reactive protein (CRP), and cerebrospinal fluid (CSF) protein were all elevated during the deterioration of her general status. Postmortem examination revealed a large tumor mass of the left adrenal gland which extended to the Th12, L1, and L2 vertebrae and remarkable brain edema. Microscopic mononuclear tumor cells were widespread but confined to the lumens of small vessels of the brain, spinal cord, spinal root and right adrenal gland, almost as if they were occluded. Cerebral white matter presented widespread multiple small infarcts and extensive myelin thinning. In addition to the left adrenal gland, interstitial invasions of tumor cells were discovered in the kidneys, iliopsoas muscles, oviducts, myocardium, lymph nodes, and thyroid gland.(ABSTRACT TRUNCATED AT 250 WORDS)

[IBL-type lymphadenopathy after infection of rubella virus]

A 52-year-old woman presented slight fever, diffuse papular skin rash and painful cervical lymph node swelling. Her lymph node swelling generally up to 3 cm in diameter, with petechiae on the lower legs and hepato-splenomegaly within a few weeks. ESR was 45 mm/h, Hb 10.0 g/dl, RBC 345 x 10(4)/microliter, WBC 22,600/microliter (atypical lymphocyte 47%), PLT 1.0 x 10(4)/microliter, GPT 91 U/L, gamma-globulin 34.3%, EBV-VCA x 2,560, EBNA x 20, and anti-rubella antibody x 512. The biopsied cervical lymph node showed histologic features of effacement of nodal architecture by an exuberant vascular proliferation accompanied with infiltration of the immunoblasts, and was diagnosed as immunoblastic lymphadenopathy (IBL)-type lymphadenopathy. The pulse therapy of methylprednisolone and high dose of gamma-globulin improved lymphadenopathy, thrombocytopenia and anemia. IBL-type lymphadenopathy after infection of rubella virus may be different from true IBL, but is important to discuss the pathogenesis of IBL.

The ribosomal protein gene cluster of Mycoplasma capricolum

The DNA sequence of the part of the Mycoplasma capricolum genome that contains the genes for 20 ribosomal proteins and two other proteins has been determined. The organization of the gene cluster is essentially the same as that in the S10 and spc operons of Escherichia coli. The deduced amino acid sequence of each protein is also well conserved in the two bacteria. The G + C content of the M. capricolum genes is 29%, which is much lower than that of E. coli (51%). The codon usage pattern of M. capricolum is different from that of E. coli and extremely biased to use of A and U(T): about 91% of codons have A or U in the third position. UGA, which is a stop codon in the "universal" code, is used more abundantly than UGG to dictate tryptophan.

UGA is read as tryptophan in Mycoplasma capricolum

UGA is a nonsense or termination (opal) codon throughout prokaryotes and eukaryotes. However, mitochondria use not only UGG but also UGA as a tryptophan codon. Here, we show that UGA also codes for tryptophan in Mycoplasma capricolum, a wall-less bacterium having a genome only 20-25% the size of the Escherichia coli genome. This conclusion is based on the following evidence. First, the nucleotide sequence of the S3 and L16 ribosomal protein genes from M. capricolum includes UGA codons in the reading frames; they appear at positions corresponding to tryptophan in E. coli S3 and L16. Second, a tRNATrp gene and its product tRNA found in M. capricolum have the anticodon sequence 5' U-C-A 3', which can form a complementary base-pairing interaction with UGA.

Preferential use of A- and U-rich codons for Mycoplasma capricolum ribosomal proteins S8 and L6

The nucleotide sequence of the 1.3 kilobase-pair DNA segment, which contains the genes for ribosomal proteins S8 and L6, and a part of L18 of Mycoplasma capricolum, has been determined and compared with the corresponding sequence in Escherichia coli (Cerretti et al., Nucl. Acids Res. 11, 2599, 1983). Identities of the predicted amino acid sequences of S8 and L6 between the two organisms are 54% and 42%, respectively. The A + T content of the M. capricolum genes is 71%, which is much higher than that of E. coli (49%). Comparisons of codon usage between the two organisms have revealed that M. capricolum preferentially uses A- and U-rich codons. More than 90% of the codon third positions and 57% of the first positions in M. capricolum is either A or U, whereas E. coli uses A or U for the third and the first positions at a frequency of 51% and 36%, respectively. The biased choice of the A- and U-rich codons in this organism has been also observed in the codon replacements for conservative amino acid substitutions between M. capricolum and E. coli. These facts suggest that the codon usage of M. capricolum is strongly influenced by the high A + T content of the genome.

Molecular cloning of ribosomal protein genes from Mycoplasma capricolum

A Bg/II-fragment from the Mycoplasma capricolum DNA cloned into pBR322 has been found to contain a cluster of ribosomal protein genes. The recombinant plasmid, pMCB1088, includes a 9 kilobase-pair insert that codes for at least eight ribosomal proteins of M. capricolum. The protein genes are expressed in Escherichia coli cells.

The ribosomal genes of Mycoplasma capricolum

The nucleotide sequence of 5S rRNA from Mycoplasma capricolum is more similar to that of the gram-positive bacteria than that of the gram-negative bacteria. The presence of two copies of rRNA genes in M. capricolum genome has been demonstrated. The two different rRNA gene clusters have been cloned in E. coli plasmid vectors and analyzed for the rRNA gene organizations, demonstrating that the gene arrangement is in the order of 16S, 23S, and 5S rDNA. The ribosomes of M. capricolum contain about 30 species of proteins in 50S and 20 in 30S subunits. The number and size of the ribosomal proteins are not significantly different from those of other eubacterial ribosomes.

The protein composition of Mycoplasma capricolum

The whole cell proteins and the ribosomal proteins of Mycoplasma capricolum ATCC 27343 have been analyzed by two-dimensional polyacrylamide gel electrophoresis. The M. capricolum cell is relatively rich in basic proteins. The number of total protein spots detected was approximately 355, which is less than one-third of that of Escherichia coli or Bacillus subtilis. In contrast, the number (30 and 20 protein species have been found to be present in the 50S and 30S ribosomal subunits, respectively) and the size of the ribosomal proteins in the M. capricolum do not seem to be significantly different from those of typical eubacteria.