Adrenal Insufficiency Associated with Small Cell Lung Cancer: A Case Report and Literature Review

症例は78歳の男性．2015年2月，全身倦怠感，食欲低下，皮膚の色素沈着，低血圧，低血糖を認め，また，胸部レントゲンにて異常陰影，エコーにて副腎腫大を指摘されたため，当院を受診した．胸部computed tomography（CT）検査では右下葉に腫瘤影，両側副腎腫大を認め，気管支鏡検査の結果，小細胞肺癌，両側副腎転移と診断した．また，血清コルチゾールの低下，adrenocorticotropic hormone（ACTH）の上昇，および，迅速ACTH試験の結果から，小細胞肺癌に合併した副腎機能不全症と診断した．カルボプラチンとエトポシドによる化学療法に加えて，ハイドロコルチゾン20 mgによる加療を開始した．その後，患者の全身症状はやや軽快したが，1コース終了後，患者の希望にて化学療法は中止とした．その後，緩和的に加療を行ったが，徐々に全身状態の悪化を認め，2015年8月に永眠された．肺癌患者における副腎転移は稀ではないが，小細胞肺癌に合併した副腎機能不全症は稀であり，副腎の90%以上の機能が破たんした場合に発症する．肺癌診療において，全身倦怠感，食欲低下，低血圧，低Na血症といった所見は，しばしば癌の進行に伴う所見として経過観察される場合がみられるが，副腎機能不全症に対する適切な治療（副腎皮質ホルモンの補充）は症状や生活の質の意義のある改善をもたらすため，両側副腎転移を有する小細胞肺癌患者では副腎機能不全症の可能性を考慮しなければならない． A 78-year-old Japanese man with fatigue, appetite loss, skin hyperpigmentation, hypotension and hypoglycemia, visited our hospital to evaluate an abnormal chest X-ray and adrenal gland swelling in echography in February 2015. Chest computed tomography showed a mass lesion in the right lower lobe and bilateral adrenal swellings, and small cell lung cancer (SCLC) with bilateral adrenal metastasis was diagnosed after bronchoscopy. According to low levels of serum cortisol, elevated adrenocorticotropic hormone (ACTH) and rapid ACTH test, the diagnosis of adrenal insufficiency associated with SCLC was made. Treatment with hydrocortisone (20 mg/day) was started in addition to systemic chemotherapy with carboplatin and etoposide. The patientʼs symptoms were slightly improved, however, systemic chemotherapy was discontinued according to the patientʼs request after 1 course of chemotherapy. Thereafter, he received only supportive care, and his general condition gradually worsened and he ultimately died in August 2015. Adrenal insufficiency associated with SCLC, which is caused by tissue destruction more than 90% of the adrenal glands, is rare although adrenal metastasis is not rare in patients with lung cancer. The findings such as general fatigue, appetite loss, hypotension, and hyponatremia are often got follow up as findings of advanced cancer, but appropriate therapy for adrenal insufficiency, supplement of the adrenal corticosteroid hormone, may lead to a significant improvement in the symptoms and quality of life in clinical practice of lung cancer. Therefore, physicians must consider potential adrenal insufficiency in lung cancer patients with bilateral adrenal metastasis.journal articl

Identity of the elusive IgM Fc receptor (FcμR) in humans

Although Fc receptors (FcRs) for switched immunoglobulin (Ig) isotypes have been extensively characterized, FcR for IgM (FcμR) has defied identification. By retroviral expression and functional cloning, we have identified a complementary DNA (cDNA) encoding a bona fide FcμR in human B-lineage cDNA libraries. FcμR is defined as a transmembrane sialoglycoprotein of ∼60 kD, which contains an extracellular Ig-like domain homologous to two other IgM-binding receptors (polymeric Ig receptor and Fcα/μR) but exhibits an exclusive Fcμ-binding specificity. The cytoplasmic tail of FcμR contains conserved Ser and Tyr residues, but none of the Tyr residues match the immunoreceptor tyrosine-based activation, inhibitory, or switch motifs. Unlike other FcRs, the major cell types expressing FcμR are adaptive immune cells, including B and T lymphocytes. After antigen-receptor ligation or phorbol myristate acetate stimulation, FcμR expression was up-regulated on B cells but was down-modulated on T cells, suggesting differential regulation of FcμR expression during B and T cell activation. Although this receptor was initially designated as Fas apoptotic inhibitory molecule 3, or TOSO, our results indicate that FcμR per se has no inhibitory activity in Fas-mediated apoptosis and that such inhibition is only achieved when anti-Fas antibody of an IgM but not IgG isotype is used for inducing apoptosis

Smoking Status and a Pulmonary Function Test in Patients with Rotator Cuff Tears

慢性閉塞性肺疾患（chronic obstructive pulmonary disease: COPD）は喫煙者の数人に1人が罹患する疾患であるが，推計患者数に比較して極めて少ない患者しか診断されていないことが問題になっている．一方，腱板断裂の発症に喫煙が関連する報告が散見されるようになった．今回我々は腱板断裂患者における喫煙状況を調査し，さらに肺機能検査より未診断のCOPD患者の把握の可能性について検討した．対象は2011年4月から2015年6月まで当院整形外科にて腱板断裂と診断され，術前肺機能検査が行われた40歳以上の連続症例150名．性別は男性が96名，女性は54名，喫煙状況は非喫煙者が59名（39.3%），前喫煙者が62名（41.3%），喫煙者は29名（19.3%）で，喫煙率は日本人全体とほぼ同様であったが，喫煙歴のある患者では1日喫煙本数21本以上が31.9%と，日本人全体の21本以上（男性15.2%，女性5.5%）に比較して多かった．気流閉塞は150名中25名（16.7%）に認め，内訳はCOPD 7名，気管支喘息3名，気管支拡張症1名，未診断14名であった．未診断の気流閉塞は，非喫煙者が7名，前喫煙者が5名，喫煙者が2名で，COPDの病期分類Ⅰ期相当が11名， Ⅱ期相当が3名で，Ⅲ期以上はいなかった．また年代別の気流閉塞は，40代（0%），50代（8.3%），60代（20.7%），70代以上（25.6%）と，年齢が高くなるほど増加した．今回の結果から，腱板断裂患者においては，喫煙歴の有無のみならず，喫煙本数にも留意する必要性を認識できた．また術前肺機能検査のデータを共有することにより，COPDの早期発見の可能性が示唆された． Although chronic obstructive pulmonary disease (COPD) affects one in several smokers, only a few patients are correctly diagnosed compared to the estimated number of patients. Several recent reports indicate that the development of rotator cuff tears is related to smoking. In this study, we investigated smoking status in patients with rotator cuff tears and evaluated the possibility of undiagnosed COPD by a pulmonary function test. The subjects were 150 consecutive patients over 40 years old, who had been diagnosed with rotator cuff tears and had been examined by a pulmonary function test before surgery in our orthopedic department between April 2011 and June 2015. They consisted of 96 men and 54 women, which included 59 non-smokers (39.3%), 62 ex-smokers (41.3%), and 29 smokers (19.3%). The smoking rate of the subjects was the same as that of the general Japanese population. However, the ever-smokers who smoked more than 21 cigarettes per day were 31.9%, which was high compared to the Japanese ever-smokers population, i.e. 15.2% of men and 5.5% of women. Twenty-five subjects (16.7%) showed airflow limitation, and they consisted of 7 cases of COPD, 3 cases of bronchial asthma, one case of bronchiectasis, and 14 undiagnosed cases. The undiagnosed cases consisted of 7 non-smokers, 5 ex-smokers, and 2 smokers. Their stages of COPD were stage 1 in 11 cases and stage 2 in 3 cases. The prevalence of airflow limitation increased with increasing age: 0% for 40’s, 8.3% for 50’s, 20.7% for 60’s, and 25.6% for over 70’s. From these results, we recognized that paying attention to the numbers of cigarettes smoked per day are important in addition to the smoking history, for the patients with rotator cuff tears. Also, sharing the data of a pulmonary function test before surgery can contribute to the early diagnosis of COPD.journal articl

不明熱と左片麻痺主症状として発症した高齢者の粟粒結核症の剖検例 (平成10年度CPPC症例)

For the men. Mycobacterium tuberculosis is one of the severe infectious disease among many fatal ones. Despite of the development of some effective drugs and the improvement of public welfare, prevalence of tuberculosis has been continuous threats for us. It is most likely that the recent reprevalence of tuberculosis have been resulted from not only the bacterial toxicity but also the increase in immunocompromised or aged populations or careless response by medical workers. We have recently autopsied a case of miliary tuberculosis in an old woman. In this case, the patient could not be diagnosed before post mortem examinations. We think this is the important case for the prevention of mycobacterial diseases, because it revealed the difficulties of differential diagnosis in tuberculosis and pointed out our inappropriate understanding of the tuberculosis. In this report, we demonstrate some pathological characteristics of the tuberculosis in aged people, and discussed the mechanisms, by which bacterial systemic colonization have been performed, and other specificities in this case

Development of Epidermoid Metaplasia of the Mucosa in Association with Esophageal Intramural Pseudodiverticulosis and Candidiasis

We report a case of epidermoid metaplasia of the esophageal mucosa that developed in a patient with a long history of esophageal intramural pseudodiverticulosis (EIPD) complicated by candidiasis. The patient, a 69-year-old man, had been treated for about 3 years for EIPD with candidiasis. After candidiasis improved, the development of epidermoid metaplasia of the esophageal mucosa was observed. It comprised longitudinally arranged, multiple, small, whitish flecks with a scaly appearance on the mucosa of the middle to lower esophagus, and pathological examination demonstrated several fine keratohyalin granules in superficial layers of the squamous epithelium. Six months later, candidiasis was almost cured, but these small flecks had slightly increased in size, and pathological examination demonstrated epidermoid metaplasia consisting of a thick, acellular keratin layer and well-developed granular layer beneath it. We considered that chronic candida esophagitis played the principal pathogenetic role in the development of epidermoid metaplasia. EIPD may have provided an environment suitable for the growth of fungi, and mucinous material contaminated by &lt;i&gt;Candida&lt;/i&gt; and excreted from the orifices of EIPD may have irritated the mucosa and induced epidermoid metaplasia. </jats:p

インターフェロンアルファ療法後多臓器不全にて死亡した慢性骨髄性白血病の剖検例

Interferone-α is used recently in the treatment of hematologic malignancies as well as viral hepatitis. Occurrences of various adverse effects associated with IFN have been reported increasingly. We report here in a case of patient who developed diverse clinical symptoms in various organs such as heart, liver, kidney following long-term IFN therapy for chronic myelocytic leukemia. The autopsy revealed the pathological changes in various tissues such as the heart muscles, the renal glomeruli and the skeletal muscles, which were confirmed by transmitted electron microscopy. The possible roles of IFN-α in those tissue damages are discussed

Subjective Happiness and Satisfaction in Postoperative Anisometropic Patients after Refractive Surgery for Myopia

Laser-assisted in situ keratomileusis (LASIK) contributes to increased patient happiness one month after surgery; however, longer term effects are unknown. We performed a retrospective cross-sectional study on 472 patients who underwent bilateral LASIK surgery to measure happiness and satisfaction with LASIK, and to identify affecting factors. Patients completed questionnaires on satisfaction with the surgery and the subjective happiness scale (SHS) before, and 1, 3, 6, and 12 months after surgery. Multiple regression analyses were performed to determine independent predictors of SHS and satisfaction scores. Mean SHS increased at one month but was similar to baseline levels by six months. The SHS of older patients was greater than younger ones at baseline and at one and three months, while satisfaction among the older group was poorer at one and three months. Multiple regression analyses revealed that the decrease in SHS score from one month to three months correlated with baseline SHS, SHS at one month, uncorrected distance visual acuity (UDVA), and age. Regression analysis revealed SHS at six months correlated with preoperative SHS, SHS at one month, and satisfaction at six months. Satisfaction at final visit correlated with age, UDVA, anisometropia, and with SHS at each visit. We conclude that happiness and satisfaction were age- and UDVA-dependent, and anisometropic patients report poorer satisfaction scores

Subjective Happiness and Satisfaction in Postoperative Anisometropic Patients after Refractive Surgery for Myopia

Laser-assisted in situ keratomileusis (LASIK) contributes to increased patient happiness one month after surgery; however, longer term effects are unknown. We performed a retrospective cross-sectional study on 472 patients who underwent bilateral LASIK surgery to measure happiness and satisfaction with LASIK, and to identify affecting factors. Patients completed questionnaires on satisfaction with the surgery and the subjective happiness scale (SHS) before, and 1, 3, 6, and 12 months after surgery. Multiple regression analyses were performed to determine independent predictors of SHS and satisfaction scores. Mean SHS increased at one month but was similar to baseline levels by six months. The SHS of older patients was greater than younger ones at baseline and at one and three months, while satisfaction among the older group was poorer at one and three months. Multiple regression analyses revealed that the decrease in SHS score from one month to three months correlated with baseline SHS, SHS at one month, uncorrected distance visual acuity (UDVA), and age. Regression analysis revealed SHS at six months correlated with preoperative SHS, SHS at one month, and satisfaction at six months. Satisfaction at final visit correlated with age, UDVA, anisometropia, and with SHS at each visit. We conclude that happiness and satisfaction were age- and UDVA-dependent, and anisometropic patients report poorer satisfaction scores.</jats:p

Clinical outcomes of KeraVio using violet light: emitting glasses and riboflavin drops for corneal ectasia: a pilot study

Background/aimsWe developed a novel technology consisting of violet light (VL)-emitting glasses and defined the combination of VL irradiation and riboflavin treatment as KeraVio. Our goal was to evaluate the clinical results of KeraVio in patients with progressive corneal ectasia.MethodsEyes were exposed to VL (375 nm, irradiance 310 μW/cm2)-emitting glasses for 3 hours daily for 6 months, and a riboflavin solution was administered onto the corneal epithelium six times during each 3-hour VL irradiation. The primary end point was a change in the maximum keratometry (Kmax) value over 6 months compared with that over the 1 year before baseline.ResultsThe efficacy of KeraVio was evaluated in 20 eyes with severe progression, and its safety was evaluated in all 40 eyes. The mean changes in Kmax over the 1 year before baseline and during the 6-month observation period were 6.03±3.41 dioptres (D) and −0.81±3.34 D, respectively (p=0.002). At 6 months, the Kmax value decreased by more than 2 D in 4 eyes (20%), remained within 2 D in 13 eyes (65%), and increased by 2 D or more in 3 eyes (15%). The corneal stromal demarcation line was identified in 16 eyes (80%), and its depth was 206.3±54.9 μm at 1 month. No significant decrease in endothelial cell density, lenticular opacity or transient corneal haze was noted.ConclusionBased on our 6-month results, daily treatment of progressive corneal ectasia with KeraVio can halt disease progression without any safety concerns.Clinical trial registration numberjRCTs032180217.</jats:sec