Multiple Low Density Areas Research Articles

Electroencephalographic findings after convulsive seizures due to cerebral arterial air embolism secondary to lung cancer: a case report

BackgroundCerebral arterial air embolism is often associated with an invasive iatrogenic etiology and a high rate of convulsive seizures. There are only a few descriptions of electroencephalogram findings in convulsive seizures due to cerebral arterial air embolism of noniatrogenic etiology. Herein, we describe the case of a patient with lung cancer and convulsive seizures with abnormalities detected on electroencephalogram caused by cerebral arterial air embolism of noniatrogenic etiology.Case presentationA 55-year-old Japanese man underwent radiotherapy and chemotherapy for cancer in the hilum of the left lung that was diagnosed after hemoptysis. One year after the diagnosis, he developed fever and chest pain that required hospitalization. At admission, he was in shock, and chest computed tomography revealed invasion of the left atrium and left main bronchus by the hilar cancer. Chest and abdominal computed tomography revealed small low-density areas within the tumor and around the intestinal membrane, which were interpreted as the presence of air due to invasion of the lung cancer. He was diagnosed with septic shock due to necrotic infection secondary to cancer invasion into the left atrium. The following day, he complained of difficulty in speaking and weakness in the left side of his body. A head computed tomography scan revealed multiple small low-density areas in the right cortex and bilateral subcortex, which were interpreted as air emboli. On day 3, he experienced generalized tonic–clonic seizures for approximately 1 minute, followed by myoclonus-like convulsions in the left lower limb and a right-sided gaze. The electroencephalogram findings after the convulsive seizures revealed partial epilepsy-like waves with intermittent spikes in the bilateral cerebral hemispheres and a diffuse slow wave in the left frontal lobe. He recovered from sepsis without recurrence of convulsive seizures; however, he died of hemoptysis on day 50 after discharge.ConclusionsElectroencephalogram findings of focal spike activities and diffuse slow waves were detected in early seizures due to cerebral arterial air embolism of noniatrogenic etiology associated with lung cancer. Additional case descriptions are warranted to establish patterns in electroencephalogram findings specific to cerebral arterial air embolism.

Incidental isolated renal mucormycosis in immunocompetent patient: a rare and atypical presentation

Mucormycosis is a group of clinical syndromes resulting from infection by one of a group of related filamentous fungi. It is an opportunistic fungal infection that rarely occurs in immunocompetent individual. Isolated involvement of any organ is rare and only a few cases of renal mucormycosis have been reported. We present a case report of atypical presentation of a case of renal mucormycosis in a healthy adult with no predisposing factors. A 48 year non diabetic immunocompetent patient underwent right nephrectomy for painful non-functioning kidney. Biopsy showed chronic pyelonephritis with broad non-septate hyphae suggestive of mucormycosis. Post op followup of patient is normal. Mucormycosis of kidney causes extensive infarction and necrosis due to direct angioinvasion and vascular thrombosis leading to fulminant acute renal failure. The disease mimics pyogenic infection leading to delay in diagnosis and hence resulting in high mortality. High index of suspicion is needed for early diagnosis. Urine and blood cultures are usually sterile. Characteristic CT findings include diffuse enlargement of the kidney with absence of contrast excretion and multiple low-density areas in the renal parenchyma representing fungal abscess. Whenever suspected, FNAC or biopsy is strongly advocated as no imaging can confirm the diagnosis. Nephrectomy or debridement of necrotic tissue along with IV Amphotericin B consist the principal treatment. Renal mucormycosis presenting an indolent course and found incidentally after nephrectomy is extremely rare. In an incidentally found mucormycosis, the role of further investigations to find the source and the role of antifungals have to be further studied.

Multiple Low-Density Areas in the Liver

Multiple Low-Density Areas in the Liver

Femoral osteopathy in Gigantspinosaurus sichuanensis (Dinosauria: Stegosauria) from the Late Jurassic of Sichuan Basin, Southwestern China

ABSTRACT We report a case of a specific osteopathy in the stegosaurian dinosaur Gigantspinosaurus sichuanensis from the Late Jurassic of Zigong City, China. The G. sichuanensis skeleton is very complete. The left femur has obvious pathological characteristics based on morphological observations. CT scans and energy spectrum data indicate the presence of multiple cystic-like low density areas internal to the pathological area, which are present in the form of multiple cystic low-density shadows in the CT data. This contrasts with the ‘normal’ area, which does not possess these characteristics. After comparing the specimen with the pathologic scapula of Yangchuanosaurus hepingensis (Dinosauria: Theropoda) also found in Zigong, we consider that the pathology in the left femur of G. sichuanensis was probably caused by a bone tumor. This is the first analysis with the aid of energy spectrum CT scanning of bone disease in fossils. This study increases the known information about paleopathology of stegosaurian dinosaurs and enriches the pathological knowledge of dinosaurs in general.

Multiple Liver Abscesses with a Skin Pustule due to <i>Chromobacterium violaceum</i>

A 69-year-old woman was admitted to our hospital with the chief complaints of fever and fatigue. We initially treated the patient for a tick-borne disease after noticing a pustule on her leg; however, abdominal computed tomography (CT) showed multiple low-density areas in the liver and Chromobacterium violaceum was isolated from a blood culture. We diagnosed her with multiple liver abscesses secondary to Chromobacterium violaceum bacteremia. The patient was successfully treated with ciprofloxacin.

Abstract B53: An autopsy case of a hepatocellular carcinoma patient with remarkable tumor necrosis immediately following glypican-3-derived peptide vaccination.

Abstract Introduction: We recently reported vaccine's safety, immunological and clinical responses in a phase I clinical trial of GPC3-derived peptide vaccine for advanced HCC patients (Clin Cancer Res 2012; 18: 3686-96). The phase I trial showed that GPC3 peptide-specific CTLs increased in peripheral blood, that many CD8 positive T cells infiltrated tumors in some patients, and the correlation between the CTL response and overall survival after the GPC3 peptide vaccination. On the basis of these results, we conducted the next trial for advanced HCC to assess histopathological findings after GPC3 peptide vaccination. We present here the clinical course and pathological study including autopsy of an advanced HCC patient, which had revealed remarkable tumor lysis immediately after the second vaccination in the ongoing clinical trial of GPC3 peptide vaccine. Study design: The trial was designed to assess clinical response, and whether tumor-infiltrating lymphocytes with anti-tumor effect are increased indeed after GPC3 peptide vaccination for advanced HCC (UMIN-CTR number: 000005093). In all cases of the trial, liver biopsies are going to be performed before and after the vaccination according to the protocol. 3.0mg of HLA-A*02 -restricted GPC3144-152 peptide (FVGEFFTDV) was administered intradermally in a liquid form emulsified with incomplete Freund's adjuvant (Montanide ISA-51VG, SEPPIC). The vaccination was scheduled every two weeks. Clinical course: A 62-year old patent, suffering from HCC refractory sorafenib therapy, was offered participation in the clinical trial of GPC3 peptide vaccine for advanced HCC. Contrast-enhanced CT before the vaccination showed multiple tumors in the liver and tumor invading into the right atrium. According to the protocol, liver biopsy was performed before the vaccination. Histopathological examination of the specimen revealed well-differentiated hepatocellular carcinoma. Immunohistochemical staining showed the expression of GPC3 and HLA class I on the membrane of carcinoma cells, and that there were little CD8-positive T cell in the specimen of liver biopsy before the vaccination. This patient had fever up, general fatigue, and remarkable impaired liver function twice subsequently after the vaccination. Contrast-enhanced CT after the second vaccination depicted multiple low density areas in the liver, indicating extended tumor necrosis. On the other hand, tumor embolism in the inferior vena cava and the right atrium was increased. Unfortunately, on day 30 after the second vaccination, he died. The autopsy was performed to determine the main causes leading to death and to evaluate the antitumor effect of vaccination. Autopsy study and immunological analysis: The main cause of death was diagnosed with circulatory failure due to tumor embolism, which occupied most of the right atrium. Histopathological examination showed the central necrosis in most of the tumor and viable carcinoma cells remained slightly around the necrotic tissue. Immunohistochemical staining showed that the infiltration of CD8 positive T cells near the residual carcinoma cells was observed, while it was not observed in the cirrhotic nodule. CD68 positive macrophages aggregated in the necrotic area around cirrhotic nodules. CD8 positive T cells also infiltrated there, suggesting probable that carcinoma cells might had been attacked by CD8 positive T cells, which might had leaded to necrosis. Ex vivo IFN-γ ELISPOT analysis of peripheral blood lymphocytes revealed vaccine-induced immune-reactivity against GPC3 peptide. Conclusion: Histopathological examination at the estimated time of the strong immunological responses can prove GPC3 peptide vaccination induce GPC3 peptide-specific CTL responses with the anti-tumor effect. Citation Format: Yu Sawada, Toshiaki Yoshikawa, Satoshi Fujii, Mari Takahashi, Tetsuya Nakatsura. An autopsy case of a hepatocellular carcinoma patient with remarkable tumor necrosis immediately following glypican-3-derived peptide vaccination. [abstract]. In: Proceedings of the AACR Special Conference on Tumor Immunology: Multidisciplinary Science Driving Basic and Clinical Advances; Dec 2-5, 2012; Miami, FL. Philadelphia (PA): AACR; Cancer Res 2013;73(1 Suppl):Abstract nr B53.

Amebic Colitis and Liver Abscess Complicated by High Serum Procalcitonin in Acute Myeloid Leukemia

We present a case of amebic colitis and liver abscess complicated by acute myeloid leukemia (AML) with high serum procalcitonin (PCT). A 61-year-old Japanese man seen at our hospital for severe diarrhea and high fever was found to have multiple ulcers in the transverse and sigmoid colon and rectum by colonoscopy and biopsies were conducted. Immature leukocytes with mild anemia and thrombocytopenia were seen in peripheral blood, necessitating bone marrow aspiration and biopsy that yielded a diagnosis of AML (FAB M4Eo). Serum C-reactive protein and PCT were extremely elevated. Blood cultures for bacteria and fungi were negative. Multiple low-density areas in the liver were found in abdominal computed tomography. Histological colon biopsy findings revealed amebic colitis, strongly suggesting amebic liver abscess. Metronidazole treatment was initiated for amebiasis and subsequent standard chemotherapy for AML was followed after fever was lowered. Hematological and cytogenetic CR was maintained with good clinical condition. Few case reports have been published in Japan to date on amebic colitis and liver abscess complicated by AML and no reports have been made on PCT elevation caused by amebiasis. In conclusion, differential diagnosis of amebiasis is necessary in addition to that of bacterial or fungal infection in serum PCT elevation.

Liver Hemorrhage Due to Idiopathic Peliosis Hepatis Successfully Treated With Hepatic Artery Embolization

Peliosis hepatis is an extremely rare condition that may cause fatal hepatic hemorrhage and liver failure. We report a case of liver hemorrhage due to idiopathic peliosis hepatis. A 60-year-old woman was admitted to our hospital with slight right hypochondriac pain. She went into hemorrhagic shock, and computed tomography (CT) showed multiple low-density areas in the right liver with massive subcapsular blood collection. Selective transfemoral arteriography of the celiac artery revealed no signs of vascular malformation or tumor stain, but showed signs of pooling in the right posterior segmental artery. The artery was embolized with particles of gelatin sponge, and hemostatic control was successful. Although peliosis hepatis is extremely rare, the diagnosis is significant because of its urgent clinical status, and transarterial embolization is a useful and minimally invasive procedure for liver hemorrhage due to peliosis hepatis.

Permucoviscosity phenotype の Klebsiella pneumoniaeによる肝膿瘍・敗血症性肺塞栓症の重症例

A 70-year-old man with diabetes mellitus seen for fever, right chest pain, and right-lung field consolidation on chest X-ray was found in thoracoabdominal computed tomography (CT) to have variable-sized nodules in both lung fields and multiple low-density hepatic areas. On physical examination, his pulse was 145 beats per minute and blood pressure 92/68mmHg, indicating a preshock state. Laboratory tests showed elevated WBC of 15,200/microL, serum-C-reactive protein (CRP) of 34.4 mg/dL, and a decreased platelet count of 16,000/microL. Suspecting liver abscesses complicated by a septic pulmonary embolism, we immediately conducted percutaneous transhepatic abscess drainage (PTAD). Liver abscess blood culture and drainage fluid grew the Klebsiella pneumoniae hypermucoviscosity phenotype, carrying the rmpA gene. Although the man had been in critical condition on admission, broad-spectrum antibiotics and PTAD treatment improved his clinical condition to where he could be discharged without problem.

Diagnostic Difficulties in Diffuse Xanthogranulomatous Pyelonephritis: A Case Report and Review of the Literature

Xanthogranulomatous pyelonephritis is a rare, severe, and chronic infection of the kidney characterized by the replacement of renal parenchyma by the xanthoma cells which is difficult to diagnose radiologically. We report a 40-year-old male who had vague abdominal mass and fever for more than 2 months. Weight loss and fatigue were the associated symptoms. Ultrasonography revealed a grossly enlarged right kidney with replacement of renal parenchyma by multiple hypoechoic areas with perinephric thickening and a large staghorn calculus. An abdominal computed tomogram demonstrated an irregular, enlarged right kidney with multiple low-density round areas and calculi. Diminished excretion of contrast media and a severe perinephric inflammatory reaction were present. A presurgical diagnosis of xanthogranulomatous pyelonephritis was made. First, drainage of the extrarenal abscess under proper antibiotic coverage was done and later, a two stage nephrectomy was done considering the debilitating condition of the patient.

A Patient with Advanced Hepatocellular Carcinoma Treated with Sorafenib Tosylate Showed Massive Tumor Lysis with Avoidance of Tumor Lysis syndrome

A 33-year-old man presented with pain and palsy of the leg in 2008 for treatment of hepatocellular carcinoma with huge distant metastases. The patient's tumors had slowly enlarged despite several treatments. Oral administration of sorafenib at 800 mg/day with careful observation was commenced in 2009. Laboratory investigations on day 7 showed massive tumor lysis. An abdominal CT showed multiple low density areas and tumor markers decreased, indicating extended tumor necrosis. In conclusion, clinicians should bear in mind not only the published adverse effects, but also massive tumor lysis, when treating patients with large tumor burden by sorafenib.

Anaplastic carcinoma of the pancreas producing granulocyte-colony stimulating factor: a case report

IntroductionThe granulocyte-colony stimulating factor-producing tumor was first reported in 1977, however, anaplastic pleomorphic type carcinoma of the pancreas producing granulocyte-colony stimulating factor is still rare.Case presentationA 63-year-old man was admitted to our hospital with body weight loss (-10 kg during months) and upper abdominal pain from 3 weeks. Abdominal computed tomography demonstrated a pancreatic tumor 10 cm in size and multiple low-density areas in the liver. On admission, the peripheral leukocyte count was elevated to 91,500/mm3 and the serum concentration of granulocyte-colony stimulating factor was 134 pg/mL (normal, < 18.1 pg/mL). Based on liver biopsy findings, the tumor was classified as an anaplastic pleomorphic-type carcinoma. Immunohistochemical staining showed that pancreatic carcinoma cells were positive for granulocyte-colony stimulating factor. The patient developed interstitial pneumonia, probably caused by granulocyte-colony stimulating factor, and died 11 days after admission.ConclusionThis is a rare case report of anaplastic pleomorphic-type carcinoma of the pancreas producing granulocyte-colony stimulating factor and confirmed by immunohistochemistry.

Disseminated Mucor infection and thrombotic microangiopathy in lymphoma-associated hemophagocytic syndrome

A 23-year-old Japanese man was admitted to our hospital because of high fever, hepatosplenomegaly, and pancytopenia. Laboratory data on admission were as follows: WBC 2.4 9 10/L, Hb 7.9 g/dL, Plt 22.0 9 10/L, AST 348 IU/ L, ALT 343 IU/L, LDH 1,302 IU/L, T-Bil 5.65 mg/dL, CRP 2.5 mg/dL, ferritin 23,724 ng/mL, and soluble CD25 32,163 U/mL. Computed tomography showed severe splenomegaly containing multiple low density areas. Bone marrow examination showed a marked increase in hemophagocytic macrophages. Although presence of abnormal cells were not apparent, oligoclonal pattern of Epstein-Barr virus (EBV) terminal repeat and abnormal karyotype with [48, XY, ?13, ?22] were detected in the specimen. He was diagnosed as lymphoma-associated hemophagocytic syndrome. HLH2004 protocol (dexamethazone 18 mg/d, cyclosporine 300 mg/d and etoposide 270 mg 9 2/week) had been started. The following two courses of ESHAP chemotherapy (etoposide 68 mg/d d1–4, methylprednisolone 500 mg/d d1–5, araC 3.4 g/d d5, and cisplatin 42 mg/ d d1–4) relieved the fever, splenomegaly, and liver dysfunction only transiently. During the subsequent CHOP chemotherapy (cyclophosphamide 900 mg, adriamycin 80 mg, and vincristine 0.5 mg on d1 without prednisolone because of continuous administration of dexamethasone), a nodular lesion measuring 2 cm appeared in the right upper lung field, and progressively increased to more than 10 cm. Because b-D glucan level was high and pharyngeal culture detected Candida species, 400 mg of fluconazole and 100 mg of micafungin sodium were started. However, fragmentation of the red blood cells became apparent in the peripheral blood smear and haemolytic markers increased in a few days. To maintain platelet count around 20.0 9 10/L, daily platelet transfusion was necessary. The value of FDP remained almost within the normal range. These results indicated the presence of thrombotic microangiopathy (TMA). Hematemesis and tarry stool followed, and panendoscopy revealed acute gastric mucosal lesions and duodenal ulcer, which needed multiple crippings. Antifungal agents were changed after seven days of treatment to 125 mg daily of amphotericin B lipid preparation (AmBisome). However, he died of hemorrhagic infarctions in the cerebellum and brain stem only in three days. Autopsy showed a white nodule with massive necrosis and fibrosis in the spleen. Microscopic examination revealed infiltration of lymphoma cells with prominent nucleoli to both red and white pulps of the spleen, and also to cervical and mediastinal lymph nodes. Immunostaining of the spleen revealed lymphoma cells positive for LCA, CD3, CD8, CD45RO, TIA-1 and granzyme B, and negative for CD4, CD5, CD20, CD56, CD57, and CD79a. The cells were also EBER-positive. These results strongly suggested that the present case was hepatosplenic T cell lymphoma associated with EBV and having an activated cytotoxic profile previously reported by Ohshima et al. [1]. Pneumonic lesion contained angiodestructive infiltration of Mucor and scattered cytomegalovirus (CMV) inclusion bodies (Fig. 1). Extensive vascular occlusion and multiple emboli including Mucor and intracellular owl eyes were N. Inagaki K. Sugimoto (&) Y. Isobe Y. Yamamoto M. Sasaki A. Kato T. Mori K. Oshimi Division of Hematology, Department of Internal Medicine, Juntendo University School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo 113-8421, Japan e-mail: ksugimot@juntendo.ac.jp

S4-01-02: Structure of the catalytic pore of gamma-secretase

A resolution revealed a 10 nm globular particle with an electron-lucent internal cavity and 2 apparent pore-like openings on the luminal and cytoplasmic surfaces. We have subsequently obtained a 3D structure at 12 A resolution by cryo-EM and single particle image reconstruction. The structure reveals multiple low-density areas and a potential lateral gate in the TM region as well as a sizable extracellular density above the putative gate that could serve as a substrate receptor. Images of the 12A structure will be shown. As gamma-secretase is active within membranes, lipid composition is likely to regulate activity. We modified a conventional gamma-activity assay to include a detergent-removal step that facilitates proteoliposome formation, increasing baseline cleavage activity 2-fold. Proteoliposomes containing cerebrosides or gangliosides significantly increased gamma-activity over a phosphatidylcholine-only baseline, whereas addition of phosphatidylinositol decreased activity. Addition of soluble cholesterol in the presence of phospholipids differentially increased the cleavage of APP-, APLP1and Notch-like substrates in a dose-dependent manner. Reconstitution of gamma-secretase in complex lipid mixtures revealed that a lipid raft-like composition supported the highest level of activity compared to other membrane compositions. Conclusions: We conclude that membrane lipid composition is a direct and potent regulator of gamma-secretase, and cholesterol plays a particularly important role.

Imaging findings of soft tissue infections in AIDS ( report of 3 cases)

Objective To evaluate X-ray,CT and MRI findings of soft tissue infections in AIDS. Methods Three cases of soft tissue infections with AIDS were retrospectively analyzed by comparing the imaging findings with pathological results.All patients were performed MRI,X-ray was in 1 case,CT was in 1 case.Results Cellulitis was in 1 case:MRI showed extended thickening of subcutaneous tissues, ill-defined hypointense areas on T_1WI and hyperintensity on T_2WI,and reticular pattern on GRE. Necrotizing fasciitis was in 1 case:MRI showed obvious thickening of subcutaneous tissues and deep fasciae, abnormally increased signal intensity on T_1 and T_2WI.Fluid collections were within muscles and muscles interval on fat-suppressed T2 WI.Tuberculosis was in 1 case:CT demonstrated multiple low density areas in the subcutaneous tissues and clear peripheral rim enhancement.MRI appeared hypointense on T_1WI and hyperintensity on T_2WI,and peripheral rim enhancement following gadolinium injection.Conclusion Infections of soft tissue are common complication in patients with AIDS,radiology is important in early diagnosis and treatment planning in this population.

Renal Lesions in IgG4-Related Systemic Disease

Recently, a new concept of IgG4-related systemic disease including autoimmune pancreatitis, characterized by a high serum IgG4 level and tissue infiltration by IgG4-positive plasma cells, has been proposed. Our aim was to investigate the renal involvement in this condition. We investigated the results of laboratory and imaging studies of the kidneys in 7 patients with IgG4-related systemic disease, and examined the renal histology in four of them. All patients showed elevated serum IgG4 levels, and 4 had autoimmune pancreatitis. The other three patients showed involvement of various extrapancreatic organs (lymphadenopathy, sialadenitis or renal insufficiency), and abundant IgG4-positive plasma cell infiltration was confirmed in their affected tissues. Six of the 7 patients showed some renal abnormalities. In one patient, hydronephrosis was observed accompanied by retroperitoneal fibrosis. Another patient showed multiple low-density areas in both kidneys by computed tomography, and gallium citrate scintigraphy showed gallium-67 accumulation in both kidneys, although renal function was normal. Four patients had tubulointerstitial nephritis. In two of them, the tubulointerstitial nephritis was diffuse. In one patient, marked diffuse but patchily distributed lymphoplasmacytic infiltration of the renal interstitium was observed. In another patient, computed tomography showed a tumor-like low-density mass; open biopsy of the mass showed aggregates of lymphocytes and plasma cells in the renal interstitium. Renal parenchymal lesions in IgG4-related systemic disease are due to dense lymphoplasmacytic infiltration of the renal interstitium, and the lesions vary from diffuse tubulointerstitial nephritis to tumor-like masses according to the distribution patterns of the infiltrating cells.

High-pressure grease injury of the face

We describe a rare case of high-pressure grease injury of the face in a 48-year-old man with severe facial edema, soft palate swelling, and bleeding from the nose and mouth. Preoperative computed tomography (CT) revealed multiple low-density areas in nasal cavity, subcutaneous tissue of the cheek, soft palate, right maxillary sinus, and right infratemporal fossa. The patient complained of a dyspnea feeling, and immediate tracheostomy was performed. The grease was removed by the Caldwell-Luc incision approach but was partially left in the infratemporal fossa. After the operation, the patient still complained cheek and temporal pain. CT and magnetic resonance imaging were useful to diagnose the remaining grease, and the remnant of the grease was completely removed by the Weber-Fergusson incision approach.

Isolated Renal Mucormycosis in Children

Mucormycosis (invasive zygomycosis) usually affects patients with debilitating conditions such as cancer and diabetes mellitus. While renal involvement is not uncommon in disseminated mucormycosis, isolated renal mucormycosis is extremely rare, especially that which does not exhibit any predisposing factors, and few cases have been reported in the literature. We report on 3 children with isolated renal mucormycosis. CASE REPORTS Case 1. A 3-month-old preterm (36 weeks) female presented with a right lumbar mass 2 months in duration without fever or hematuria. The mother appeared healthy, and AIDS and fungal evaluations were negative during gestation. On physical examination a well demarcated hard mass about 6 cm in diameter was palpated in the right lumbar region, which was shown on B-ultrasound (B-US) to be a solid mass of the upper kidney. Right nephroblastoma was diagnosed preoperatively. During exploratory surgery a 6.0 6.0 5.0 cm mass was located in the upper part of the right kidney. The upper part of the mass adhered closely to the hepatic flexure of the colon. Many swollen lymph nodes were found in the mesentery of the ascending colon. Complete resection was difficult, so the majority of the mass was excised and swollen lymph nodes in the mesentery were biopsied. Case 2. A 12-year-old otherwise healthy student presented with a 1-month history of fever followed by 1 week of severe right lumbar pain and hematuria. No history of diabetes mellitus or AIDS was noted. Initial treatment with cephalosporin was ineffective and B-US detected a renal abscess. On admission to the hospital the patient had a body temperature of 40C, and there was marked tenderness and percussion pain in the right lumbar region and slight tenderness in the bladder region. Abdominal computerized tomography showed diffuse enlargement and multiple low density areas of the right kidney with several small perirenal abscesses. Renal perfusion scans demonstrated a nonfunctioning right kidney. Renal abscess was diagnosed and surgically managed. During surgery the right kidney became markedly swollen and soft, and many foci could be seen. There was about 100 ml yellow-white pus in the abscess, which was aspirated for fungal culture, and renal parenchyma was biopsied. Case 3. A 14-year-old boy was hospitalized with fever, hematuria and flank pain 1 month in duration, deteriorating with dysuria, polyuria and pyuria for 2 weeks. No predisposing diseases or recent drug abuse could be elicited. Gross hematuria was observed, routine urinalysis revealed numerous hyphae of Mucor corymbifer and red blood cells were (4). Body temperature was 39.5C. Marked tenderness and percussion pain were noted in the right lumbar region and bladder region. B-US detected a low echo right kidney. Excretory urography and renal perfusion showed a nonfunctioning right kidney. Therefore, renal mucormycosis with infarction was diagnosed. The patient was administered systemic amphotericin B and subsequently underwent right nephrectomy. Pathological results. Frozen sections in cases 1 and 2 demonstrated the mass was mainly inflammatory and necrotic tissue, and many fungi were scattered in the tissue. Hematoxylin and eosin sections confirmed the diagnosis of mucormycosis in all 3 cases, although fungal cultures were negative in case 2. The diagnostic criteria were established only when frozen and hematoxylin and eosin sections were consistent with acute purulent inflammation, and the broad nonseptate fungal hyphae with right angled branches, typical of M. corymbifer, were detected in the tissue (fig. 1). The hyphae were readily observed by silver staining and periodic acidSchiff reaction (fig. 2). The swollen lymph nodes in case 1 were confirmed to be reactive proliferation of inflammation without M. corymbifer. Antifungal treatment (intravenous amphotericin B lipid complex at a daily dose of 2 mg/kg and a total dosage of 300 to 2,160 mg during 3 to 4 weeks, followed by 30 to 50 mg/kg 5-fluorocytocine orally per day for 3 months) followed or was continued after nephrectomy. The 3 children recovered uneventfully, and hepatic and renal function remained normal during followup. DISCUSSION Mucormycosis occurs predominantly in immunocompromised patients, in whom it carries a serious prognosis. Mucormycosis can usually be divided into 5 different subtypes— cerebral, pulmonary, gastrointestinal, cutaneous and systemic, none of which is uncommon. Renal involvement is

A CASE OF LEIOMYOSARCOMA OF THE DUODENUM CAUSING MULTIPLE PYOGENIC LIVER ASSCESSES

A case of leiomyosarcoma of the duodenum causing multiple pyogenic liver abscess is reported. A 55-year-old man was admitted to the hospital because of lasting fever of unknown orign. Ultrasound scan of the abdomen revealed multiple low density areas in the liver parenchyma, also seen CT scanning as multiple areas of low attenuation coefficient. And CT scanning of the abdomen depicated a duodenal hypervascular mass measuring 4.0cm in diameter. Duodenoscopy revealed a submucosal tumor with ulceration. The clinical presentation was consistent with that of liver abscess. But the possibility of the necrotic hepatic metastases could not be ruled out. Pancreatoduodenectomy was performed. Histopathologically this tumor was leiomyosarcoma arising from the descending portion of the duodenum with multiple pyogenic hepatic abscesses. It is etiologically thought that the leiomyosarcoma was associated with central necrosis which had a communication with gastrointestinal lumen to form infectious foci locally, and the infection affected the liver via portal veins to form liver abscesses.

脳血管攣縮による脳梗塞のCT所見

We analyzed the type and the distribution of low density areas (LDAs) on CT scans caused by vasospasm, and investigated the relation between LDAs and clinical features, focusing on the influence of aging on CT findings. The subjects of this study are 159 patients (70 males and 89 females) who underwent aneurysm surgery within 7 days after the onset of hemorrhage over the past 14 years and were followed up by sequential CT scans. They were divided into 2 aged groups: (A)≤59 yrs (96 patients), (B) 60 yrs≤(63 patients). Of the 159 patients, 55 (35%) developed symptomatic vasospasm. Subsequent CT scans showed 66 LDAs in 42 patients (26%). There was no significant difference in incidence of symptomatic vasospasm and LDAs between the 2 age groups. Multiple LDAs and bilateral involvement were frequently observed in the aged group.We advocated the following classification for the appearance of LDAs: (1) Major type, (2) Branch type, (3) Perforator type, (4) Subcortical type and (5) Watershed type. The Major type often appeared as a single LDA. In contrast, most of the subcortical type and a number of the Branch and Perforator types were concomitant with other types of LDAs. The Watershed type was not observed alone. The outcome of the Major type was significantly worse than that of other types of LDAs. The outcome of the Branch and Perforator types was not unfavorable unless eloquent areas were involved. However, the Subcortical and Watershed types were usually accompanied by other types of LDAs that caused poor prognosis. In the aged group, the Subcortical and Watershed types were frequently observed. This finding suggests that elderly patients may lack sufficient compliance to tolerate ischemic insult after vasospasm.