Hidetoshi Oda

Successful Treatment with Cyclosporin in Adult-Onset Still Disease Manifesting as Acute Hepatitis with Marked Hyperferritinemia

A 48-year-old woman was admitted because of spiking high fever, sore throat, and jaundice. A diagnosis was made of adult-onset Still disease (AOSD) presenting with acute hepatitis and very high serum ferritin levels (32,240 ng/mL), and she was treated with 2 courses of pulse therapy of methylprednisolone (2 g/day for 3 days) followed by 40 mg/day prednisolone. Subsequently, the serum level of ferritin decreased, but serum total bilirubin increased to 17.3 mg/dL. Therefore, cyclosporin was administered orally. Within the next 3 months, results of liver function tests, as well as serum levels of ferritin, soluble interleukin-2 receptor, interferon-gamma, interleukin-6, and tumor necrosis factor-alpha gradually returned to within normal limits, and cyclosporin administration was subsequently reduced gradually. The clinical presentation suggests that AOSD should be considered when liver dysfunction is accompanied with high fever and extreme hyperferritinemia, and that treatment with cyclosporin or other immunosuppressive drugs that selectively suppress cytokine production by helper T cells is a valuable option in the treatment of AOSD with very high serum ferritin levels.

ENDOSCOPIC SUBMUCOSAL DISSECTION OF A MINUTE INTRAMUCOSAL ADENOCARCINOMA IN BARRETT'S ESOPHAGUS

A 73‐year‐old man with short segmental Barretts esophagus underwent esophagoscopy, and a slightly depressed, discolored lesion was found on the anterior wall of the lower esophagus. Under a provisional diagnosis of differentiated adenocarcinoma without local lymph node metastasis, endoscopic submucosal dissection (ESD) was carried out. En bloc resection with tumor‐free lateral/basal margins was accomplished without complication. The resected area was 12 × 15 mm in size, whereas the neoplastic lesion was 4 × 4 mm. Histopathological examination confirmed intramucosal well‐differentiated tubular adenocarcinoma without angiolymphatic invasion adjacent to the muscularis mucosae. Repeated esophagoscopy 6 months after ESD showed neither locally recurrent nor metachronous lesions. Considering that Barretts esophagus is a precancerous condition, one may recommend eradication of both the neoplastic and non‐neoplastic lesion with using ESD.

Cyst formation of duodenal heterotopic pancreas accompanied by pancreas divisum.

Heterotopic pancreas and pancreatic divisum are wellknown anatomic anomalies of the pancreas (1). Although heterotopic pancreas is usually asymptomatic, it may become clinically evident with any symptoms related to complications, including ulceration, bleeding, hyperinsulinism, obstructive jaundice, and gastric outlet obstruction (2). In addition, cystic degeneration is an uncommon and serious complication of heterotopic pancreas (3–5). In this article, we report an unusual case of cyst formation in duodenal heterotopic pancreas accompanied by pancreas divisum.

Interferon Alfa-2a Treatment for Chronic Hepatitis C without Cirrhosis and Its Effects on the Incidence of Hepatocellular Carcinoma

The aim of interferon treatment for chronic hepatitis C is eradication of the hepatitis C virus during the early stages of the disease to prevent progression to liver cirrhosis or hepatocellular carcinoma. However, the effects of interferon on preventing the development of hepatocellular carcinoma for chronic hepatitis C without cirrhosis remain obscure. We wished to study these effects. In this retrospective study, we followed up 66 patients with chronic hepatitis C who were treated with interferon alfa-2a (total dose 324 to 792 MIU) for an average period of 3 years after treatment. Of these 66 patients, 3 patients developed hepatocellular carcinoma during the follow-up period (range, 0.3 to 2.8 years; yearly incidence 1.5%). All 3 patients were among 27 patients who did not respond to interferon treatment. Of these 3 patients, 1 patient developed liver cirrhosis after interferon treatment, and the histologic staging of the remaining 2 patients before interferon treatment was F3, according to the new Inuyama classification. None of the 18 patients who were complete responders to interferon treatment or the 21 patients with incomplete responses developed hepatocellular carcinoma. Our results suggest that patients with chronic hepatitis C who have no response to interferon treatment and histologically advanced disease should be closely followed up after interferon treatment, although the mechanism of malignant transformation to hepatocellular carcinoma in patients with chronic hepatitis C virus infection is still obscure.

Granular Cell Tumor of the Cecum: Two Case Reports

Abstract: We experienced two cases of cecal granular cell tumor. The site of occurrence and diagnosis are discussed in relation to the literature on granular cell tumor of the large intestine. Most granular cell tumors of the large intestine tend to remain constant in size, showing the morphology of a submucosal tumor. Endoscopic excision was considered a useful diagnostic procedure. S‐100 protein was positive in most cases, supporting the hypothesis that the tumor is derived from Schwann cells.

Hepatitis B virus reactivation in patients with rheumatoid arthritis: A single-center study

Abstract Objectives: This study aimed to investigate the frequency of hepatitis B virus (HBV) reactivation in patients with rheumatoid arthritis (RA) and to verify the guidelines relating to HBV reactivation in Japan. Methods: We retrospectively investigated 1351 RA patients who were treated with antirheumatic drugs at our hospital. Results: Fifty patients (3.7%; 50/1351) were determined to be HBV carriers and 360 patients (26.7%; 360/1351) had resolved infections. HBV reactivation occurred in six cases (1.7%: 6/360) with resolved infections, of whom, two cases (0.6%; 2/360) developed de novo HBV infections. Eleven of the patients who were HBV carriers received a nucleoside analogue (NA) prophylactically. In all of the cases, the HBV-DNA levels became undetectable and the patients’ liver function normalized. Sixteen patients, who had lower titers of the HBV surface antigen and undetectable HBV-DNA levels, did not show HBV reactivation in the absence of NA therapy. Conclusions: The results from this study suggest that HBV reactivation might not be so frequent among RA patients, and that reliable indicators for prescribing a NA should be clarified for RA patients.