Superior sagittal sinus thrombosis presenting with subarachnoid hemorrhage in a patient with aplastic anemia

A 54-year-old female, who had been treated for aplastic anemia by metenolone acetate since 1981, developed a sudden unconsciousness in September 1995. On admission, she was drowny, CT showed a subarachnoid hemorrhage (SAH) in the right Sylvian fissure. Angiography demonstrated a complete occlusion of the superior sagittal sinus. The SAH was assumed to be originated from rupture of the right Sylvian vein, which was irregularly dilated on angiography. The dural sinus thrombosis was thought to be caused by a long term use of metenolone acetate, and it was discontinued. But her platelet count dropped due to the aggravation of aplastic anemia, and she developed repeated hemorrhagic infarction. An active anticoagulant therapy for the dural sinus thrombosis was thought to be inappropriate because she had the aplastic anemia and the hemorrhagic infarction recurred. We have successfully treated this case by mild anticoagulant therapy with nafamostat mesilate (Futhan).     

Gastric cancer occurring in a patient with Plummer-Vinson syndrome: report of a case

We report herein the unusual case of a 59-year-old woman with Plummer-Vinson syndrome who developed gastric cancer. The patient had a longstanding history of dysphagia and iron deficiency anemia, for which she had sporadically taken iron supplements that improved the dysphagia to some extent, but not completely. Owing to her tolerance of the dysphagia, she had not been taking iron supplements for the past 17 years. On admission, she was in fair nutritional condition and not anemic. Blood chemistry results were all normal, including the serum iron level. Gastrointestinal radiographic series demonstrated cervical esophageal webs and advanced gastric cancer. Her dysphagia was successfully treated by endoscopic bougienage through the webs, and a distal partial gastrectomy with nodal dissection was performed. Histology of the resected stomach revealed atrophic mucosal change and, by chance, an adenomatous lesion in addition to adenocarcinoma. Her postoperative course was uneventful and she is now well, without any signs of recurrence. Although Plummer-Vinson syndrome is known to be associated with upper alimentary tract cancers, gastric cancer is extremely rare. A discussion on the etiology of Plummer-Vinson syndrome and its link with potential carcinogenesis follows this case report.     

Cerebral infarction in Crohn's disease

Thromboembolic complications in Crohn's disease are not rare. Most of them are disseminated vascular thrombosis or pulmonary emboli. Cerebral artery thrombosis is a rare complication of Crohn's disease. We describe a 27-year-old woman who had Crohn's disease for 8 years, with exacerbation 3 months before admission. She had bloody diarrhea, abdominal pain, weight loss, weakness, and anemia. Hemoglobin was 6.3 g/dl and she received 3 packed cell transfusions the day of admission. Her hemoglobin level rose to 13 g/dl. 2 days after admission she had generalized tonic-clonic convulsions, followed by hemiparesis. EEG and CT examinations showed right temporal lobe infarction. Many studies report a hypercoagulable state in Crohn's disease, which results in a thromboembolic tendency that is potentially fatal.     

A case of malignant lymphoma with a metastasis to the lateral rectus muscle

We reported a 75-year-old woman with malignant lymphoma who had a metastasis to the right lateral rectus muscle. She was well until two months earlier, when a tumor in the left thigh began to enlarge. Ten days before admission, she noticed medial deviation of the right eyeball. Neurological examination showed the right esotropia with isolated paralysis of the right lateral gaze. She denied double vision. MR imaging demonstrated a swelling of the right lateral rectus muscle. Gallium scanning revealed abnormal accumulation in the right orbit and the left thigh. The tumor in the left thigh was histologically diagnosed as non-Hodgkin's lymphoma, diffuse large cell type. Discrete extraocular muscle metastasis is rare and unreported for malignant lymphoma. Reported cases of breast and thyroid cancers metastatic to the extraocular muscles did not develop diplopia similar to our case. The rapid growth of metastases to the extraocular muscles produces a large visual axes deviation, therefore no diplopia may be elicited.     

Moyamoya disease associated with pulmonary sarcoidosis--case report

A 61-year-old female presented with a unique case of moyamoya disease associated with pulmonary sarcoidosis. She was admitted for sudden onset of left temporalgia with episode of numbness on face, tongue, and upper extremity on the right side. The next morning, she had symptoms of Gerstmann syndrome and her ability to speak was disturbed. Her medical history included radical resection of lung cancer on the right side. She had no symptoms of pulmonary sarcoidosis. Neuroimaging showed an infarction in the left occipital lobe. Angiography showed occlusions of the bilateral internal carotid arteries at the supraclinoid portions. Subsequently, a left superficial temporal artery-middle cerebral artery anastomosis with encephalo-myo-synangiosis was performed. Ninety-three days after admission, she suddenly developed dyspnea which resulted in death 3 hours later. Autopsy findings showed typical epithelioid granulomas of sarcoid type in the lymph nodes of the peribronchus, lung, and liver. Thrombotic emboli were found in the bilateral pulmonary arteries, and marked fibrous intimal thickening in the bilateral internal carotid arteries. Immunological reaction with inflammatory events may cause pathological changes in patients with moyamoya disease or sarcoidosis. The co-incidence in this case suggests that some common inflammatory events may be involved in the pathogenesis of these diseases.     

Lyme neuro-borreliosis in a 66-year old women. Differential diagnosis of cerebral metastases and cerebral infarction]

A 66-year-old woman with medically treated hypertension and a recent operation for breast cancer was admitted because of burning pain localized between her shoulder blades and a paretic, dysaesthetic right arm. CSF examination revealed lymphocytic pleocytosis and specific IgM Borrelia burgdorferi antibodies. CT was normal. The patient was treated intravenously with high doses of penicillin for 14 days, and within one month of admission she had recovered completely neurologically. During the first days of treatment a drop in blood pressure, ECG changes, and further neurological changes were observed, but disappeared spontaneously within three days. The patient did not recall a tick bite, and the case illustrates that neuroborreliosis may be a differential diagnosis to stroke or cerebral neoplasms in elderly patients.     

Nedocromil sodium is effective in the treatment of mild and moderate allergic asthma caused by Dermatophagoides pteronyssinus

A case of acquired hemophilia A in a 65-year-old woman is presented. The patient had been subjected to cholecystectomy 2 months before the bleeding tendency appeared. On admission, she had easy bruising and prolonged activated partial thromboplastin time, but during hospitalization she had severe hemorrhage into the right gluteal and femoral muscles. An inhibitor of the factor VIII coagulant protein (FVIII:C) of high Bethesda titer was found in her serum. The patient was successfully treated with activated recombinant human factor VII (rhFVIIa) and immunosuppression. We conclude that rhFVIIa is a safe, effective, and fast-acting preparation for the treatment of severe hemorrhage in patients with acquired hemophilia A, and that the simultaneous administration of azathioprine and corticosteroids may suppress production of the inhibitor.     

Metastatic renal tumor of malignant salignant salivary-gland-like tumor of the lung: A case report

A 17-year-old woman was admitted to our hospital for the investigation of asymptomatic gross hematuria. Twenty nine months ago, she had received the right lower lobectomy because of the malignant salivary gland type mixed tumor of the bronchus. The intravenous pyelography and the right retrograde pyelography showed the irregular wall of the right renal pelvis. The computerized tomography showed a hypodense tumor which occupied the lower half of the right kidney. Cystoscopy showed bleeding from the right ureteral orifice. Chest X-ray revealed multiple lung metastases at the first examination, but right nephrectomy was performed because gross hematuria continued. The tumor thrombus, which spreaded into vena cava, was removed. The pathological diagnosis was the metastatic renal tumor of malignant salivary gland type mixed tumor. The patient died 102 days postoperatively.     

Original article (II): materials and methods

We experienced five patients with prostate cancer with disseminated intravascular coagulation syndrome (DIC) at the first presentation at Gunma University Hospital and affiliated institutions between 1991 and 1997. Their average age was 68 years, average DIC score at the first presentation was 10 and prostate specific antigen (PSA) level was more than 700 ng/ml. All of them had multiple bone metastases. The therapy for DIC and hormonal therapy for prostate cancer were simultaneously started at the first presentation before prostate needle biopsy, but all patients died. The average number of days from the start of DIC to death was 685 days. The patients initially showed a good response to therapy, but their conditions soon aggravated. The prognosis was extremely poor, but some proper therapies lead to the prognosis which was equal to that of prostate cancer in Stage D2 without DIC.     

Urodynamics of the upper urinary tract

A 64 year old woman with a past history of panhysterectomy and oophorectomy for carcinoma of the body of the uterus (1950) and partial colectomy for carcinoma of the colon (1971), presented in 1972 with severe weakness of the proximal girdle muscles and histological evidence of polymyositis. A detailed search disclosed no tumor and she was treated with prednisone. Two years later, investigations for iron deficiency anemia revealed two polyps in the colon. Pathological examination of the resected colon disclosed two separate foci of adenocarcinoma and a number of adenomatous polyps. Three months later, further investigations for melena led to the discovery of a gastric carcinoma. Due to the extent of the tumor, she was subjected to gastrectomy. splenectomy, and excision of the tail of the pancreas, but died of postoperative complications. At autopsy, no residual cancer was detected, but a meningioma was found. The association of polymyositis with malignant tumors has been recognized for a long time, but only two previously reported patients have had more than one cancer. Although a causal relationship is difficult to establish, continued vigilance for neoplasms is advocated during the follow-up period.     

Guided tissue regeneration therapy of 203 consecutively treated intrabony defects using a bioabsorbable matrix barrier. Clinical and radiographic findings

We report a 64-year-old woman who developed nausea, headache, and consciousness disturbance. She was well until four years before the onset of her neurologic illness when (April of 1990 at her 59 years of the age) she was found to have an early cancer in her anterior wall of the lower stomach. Subtotal gastrectomy was performed and the operative result was reported as curative. Four years after the surgery (December of 1994 at her 64 years of the age), she noted suboccipital headache and nausea which had become progressively worse and she was admitted to our service on May 24, 1995. On admission, she appeared chronically ill but general physical examination was unremarkable with normal vital signs. Neurologically she was alert and not demented, and the higher cerebral functions were intact. Cranial nerves were also unremarkable. She was able to walk in tandem and on heels. No motor weakness or ataxia was noted. Deep tendon reflexes were moderately increased, however, no Babinski sign was noted. Although she had headache, no meningeal signs were seen. Slight superficial and vibratory sensory loss was noted in both feet. Routine blood work was again unremarkable except for slight increase in CEA to 8.3 ng/dl (N < 5 ng/dl). The opening pressure of lumbar CSF was 180 mm H2O and the CSF contained 39 cells/microliter, 79 mg of protein, and 10 mg/dl of glucose. Approximately half of the cells were atypical malignant cells. Plain CT was unremarkable, however, tentorial border showed enhancement after contrast infusion. FGS showed no malignant tumors in the stomach. She was treated with intravenous glycerol and whole brain radiation, however, she continued to complain of severe headache, and her sensorium started to be disturbed one month after the admission. Follow-up cranial CT scan revealed enlargement of the lateral and the third ventricles. Her consciousness progressively deteriorated and she became comatose three months after the admission. Repeated cranial CT scan showed enlargement of the ventricles, but no mass lesions were seen within the brain. She developed respiratory arrest on September 25 of the same year. She was discussed in a neurological CPC and the chief discussant arrived at the conclusion that the patient had a gastric cancer with meningeal seeding developing meningeal carcinomatosis. The cause of deep coma was ascribed to damage of cerebral cortical areas secondary to metastatic carcinoma cells and fibrinous materials in the surface of the brain. Postmortem examination revealed thickening and clouding of leptomeninges of the cerebral convexity. On histologic observation, patchy areas of fibrous thickening were seen in the cerebral leptomeninges; in such areas, adenocarcinomatous cells were seen scattered. The basal meninges were free of carcinoma cells, however, leptomeninges of the cerebellum and brain stem tegmentum contained scattered carcinoma cells. The lateral and the third ventricles were enlarged, however, insides of the brain were free of pathologies; the ependymal layer were intact. In the stomach no carcinoma cells were remaining. Pneumonic changes were seen in the right upper and the left lower lobes which appeared to be the direct cause of her death. No evidence of tentorial herniation was noted. The cause of her deep coma was not clearly determined, however, combination of hydrocephalus and cortical malfunction due to leptomeningeal carcinoma cell infiltration and fibrinous material accumulation appeared to have played a role.     

A case of lymphocytic interstitial pneumonia

A 56-year-old female was admitted on November 1995 to our hospital because of the abnormal shadow on her chest X-ray. Although the chest X ray film revealed diffuse reticulonodular shadows in the bilateral lung fields and right hilar lymphadenopathy, she had not any complaints. Furthermore, mediastinal lymphadenopathy and polyclonal hypergammaglobulinemia were noted. For a further examination, transcutaneous thoracoscopic lung biopsy was performed on August 1996. The lung specimens showed a interstitial infiltration of small lymphocytes exclusively around bronchioles. And the diagnosis of lymphocytic interstitial pneumonia (LIP) was made. She had been suffered from bronchial asthma for 27 years. This is the first report of LIP accompanied with bronchial asthma. Its relationship between LIP and bronchial asthma remains unclear. In the 2 years of follow-up, she remained asymptomatic with unchanged chest radiogram. And her pulmonary function was preserved for the 2 years. But lymphocytic interstitial pneumonia may induce malignant lymphoproliferative disease potentially, we should carefully follow up.     

A case of superior vena cava syndrome caused by Klebsiella pneumoniae

A 27 yr old man presented with productive cough, fever and manifestations of superior vena cava syndrome. He was an alcoholic but had been in good health until 3 days prior to admission. The physical examination, the chest radiograph and the results of the sputum culture were compatible with Klebsiella pneumoniae pneumonia of the right upper lobe. The superior vena cava scintigram using technetium-99m showed near total occlusion of the superior vena cava, while sputum cytology, chest computed tomography, and bronchoscopy were all negative for malignant aetiology. Antibiotic therapy brought about slow resolution of the pneumonia and also of the superior vena caval obstruction. The follow-up scintigram showed normalized venous flow of the superior vena cava. To our knowledge, this is the first case of superior vena cava syndrome developed in probable association with Klebsiella pneumoniae pneumonia.     

Phase I study of orally administered UFT plus l-leucovorin

We describe the case of a 44-year-old woman with a delayed hemolytic transfusion reaction (DHTR). She had a history of two pregnancies and a blood transfusion, the details of which were unknown. At the time of her first vascular surgery on November 15, 1989, she received 1200 ml of crossmatch-compatible concentrated red blood cells (CRC). Before the first operation, screening for anti-RBC antibodies (Ab) was negative. At the time of the second admission on Feburary 15, 1996, anti-E Abs were detected by indirect antiglobulin test. She received 560 ml of E-antigen-negative, crossmatch-compatible, CRC for treatment of anemia on March 1 and 2, 1996. After this transfusion, total bilirubin (1.6 mg/dl) and lactate dehydrogenase (1355 IU/ml) were elevated on March 12, 1996. She had no evidence of clinical hemolysis. We suspected DHTR from these data, and therefore screened for anti-RBC Abs. Anti-E, Jka, Dia, Fyb, and S Abs were detected in blood samples obtained from the patient on March 12, 1996. Anti-E, Jka Dia, and S Abs were present more than 1 month and anti-Fyb Ab was disappeared at 18 days after transfusion.     

The indispensable anamnesis: in-vitro fertilization in a woman under treatment for melanoma

A couple consulted the gynaecologist repeatedly because of a primary fertility disorder. When they had desired children for 8 years, no pregnancy had yet occurred. In-vitro fertilization (IVF) treatment was started. A few days after the beginning of the hormonal treatment that precedes the IVF procedure, the woman noted a swelling in the right inguinal area for which she consulted the surgeon. This swelling was found to be a metastasis of a melanoma that had been removed from her leg 6 months previously. The gynaecologist was not aware of this case history and the surgeon was not informed of the started IVF treatment. As was found later, this was in accordance with the couple's wishes. The first IVF treatment resulted in a pregnancy that ended with the birth of a healthy boy. The placenta showed melanomatous metastases and the mother died 2 months after the birth of her son.     

An unusual case of large right atrial myxoma

A case of right atrial myxoma is described. The patient had vague and variable symptoms and it was not until five years after first presentation that she had developed clinical and electrocardiographic evidence of right atrial hypertrophy, and angiocardiographic evidence of a fist-sized myxoma which was subsequently removed surgically.     

Diagnosis from thyroid aspirates. Is the cytopathologist handicapped if not fully informed about the patient?

OBJECTIVE: When fine needle aspiration cytology (FNA) of the thyroid is performed as a first-line test, the cytopathologist cannot be fully informed about the patient's data. The authors investigated whether this decreases the accuracy of FNA and results in consequences for the patient. STUDY DESIGN: FNA smears of 202 patients, 190 with benign and 12 with malignant thyroid disease, were reevaluated, supplying the cytopathologist first with only information from the case history known already at the initial admission, and subsequently with full data. RESULTS: The FNA diagnoses were corrected in 13 cases; in 8/13 they showed a more serious finding. The therapeutic modality was changed in only one case. No corrections were made in the ultimately malignant cases. CONCLUSION: In several cases the cytopathologist may be handicapped by receiving only partial information about the patient, but in our patients this had no demonstrable adverse consequences. Thus, FNA can be performed upon patient's admission.     

Sarcoidosis in a patient with autoimmune hemolytic anemia

A 65-year-old woman was admitted to our hospital because of severe anemia. A skin biopsy was done in January 1994 and sarcoidosis was diagnosed. Diffuse reticular shadows were seen in both lung fields on a chest X-ray film and mediastinal lymph node swelling was seen on a chest CT scan. She was followed as an outpatient and was not treated. She suddenly experienced vertigo and general fatigue in March 1995. Laboratory findings on admission were as follows: Hb 6.2 g/dl, MCV 115.9 fl, Ret 198%, LDH 732 IU/L, I-Bil 1.9 mg/dl, and Coombs' test was positive. Autoimmune hemolytic anemia was diagnosed, and she was treated with prednisolone (1 mg/kg). As of the time of this writing, she has no relapse of hemolytic anemia though prednisolone was discontinued 6 months ago.     

Treatment of fibrous dysplasia involving the proximal femur

Bone marrow transplant-associated thrombotic microangiopathy (BMT-TM), usually associated with thrombocytopenia, microangiopathic haemolytic anaemia (MAHA) and renal insufficiency, has been reported to occur approximately 5-6 months after BMT. We report a case of relapsed malignant lymphoma complicated by BMT-TM of hyperacute onset, which has never been described in the literature. Our patient, a 52-year-old male, developed MAHA with gross haematuria, thrombocytopenia, lactate dehydrogenase elevation and renal insufficiency 2 days after autologous PBSC transplantation following high-dose chemotherapy. Supportive treatment, ie glucocorticoid, fresh frozen plasma and haemodiafiltration were given, and thereafter the BMT-TM gradually improved. In heavily pretreated patients, caution should be exercised for possible occurrence of the BMT-TM of hyperacute onset.     

Extraperitoneal anterior approach to renal vessels in radical surgery of renal cancer

A 63-year-old female developed the chest wall tumor protruding into the right thoracic cavity. She consulted our hospital complaining of chest pain. 20 years before this episode, she had undergone tumor extirpation combined with the partial resection of adherent anterior chest wall and the diaphragm for large benign solitary fibrous tumor of the pleura. Because of the difficulty in making diagnosis by needle biopsy, operation (re-tumor extirpation combined with the chest wall) was done. Histological examination revealed that the tumor was malignant solitary fibrous tumor. We concluded that the tumor was the malignant recurrence of the benign solitary fibrous tumor resected 20 years before. Occasionally, benign solitary fibrous tumor of the pleura recurs and behaves more aggressively than primary, but such a long latent period as 20 years is quite uncommon. So we present the case and the review of the literature.