Takahiro Nada

Lanthanum Deposition in the Stomach: Usefulness of Scanning Electron Microscopy for Its Detection

After having been treated with lanthanum carbonate administration for 4 years for hyperphosphatemia, a 75-year-old Japanese woman undergoing hemodialysis was diagnosed with lanthanum phosphate deposition in the stomach. The deposition, seen as white microgranules, was observed using esophagogastroduodenoscopy with magnifying observation. To the best of our knowledge, these are the minutest endoscopy images of lanthanum phosphate deposition in the gastric mucosa. Scanning electron microscopy (SEM) observation enabled easier identification of the deposited material, which was visible as bright areas. The present case suggests the usefulness of SEM observation in the detection of lanthanum phosphate deposition in the gastrointestinal tract.

Myopathy and Eosinophilic Pneumonia Coincidentally Induced by Treatment with Daptomycin

A 34-year-old man with 22q11.2 deletion syndrome (DiGeorge syndrome) concurrently suffered from myopathy and eosinophilic pneumonia shortly after receiving daptomycin (DAP) for right-sided infective endocarditis. The simultaneous occurrence of these phenomena in relation to DAP therapy has not been previously well described. An allergic reaction was suspected as a possible etiology of these DAP-related complications. This case highlights the need for close observation in order to detect both musculoskeletal and respiratory disorders from the start of DAP therapy. Physicians should pay more attention to this new drug, which is expected to be frequently used in various clinical settings.

Interaction between orexin A and bone morphogenetic protein system on progesterone biosynthesis by rat granulosa cells

The involvement of orexins in reproductive function has been gradually uncovered. However, the functional role of orexins in ovarian steroidogenesis remains unclear. In the present study, we investigated the effects of orexin A on ovarian steroidogenesis by using rat primary granulosa cells that express both OX1 and OX2 receptors for orexins. Treatment with orexin A enhanced progesterone, but not estradiol, biosynthesis induced by FSH, whereas it did not affect basal levels of progesterone or estradiol. In accordance with the effects on steroidogenesis, orexin A increased the mRNA levels of progesterogenic enzymes, including StAR, P450scc and 3βHSD, but not P450arom, and cellular cAMP synthesis induced by FSH. Under the condition of blockage of endogenous BMP actions by noggin or BMP-signaling inhibitors, orexin A failed to increase levels of progesterone synthesis induced by FSH treatment, suggesting that endogenous BMP activity in granulosa cells might be involved in the enhancement of progesterone synthesis by orexin A. Treatment with orexin A impaired Smad1/5/9 activation as well as Id-1 mRNA expression stimulated by BMP-6 and BMP-7, the latter of which was reversed by treatment with an OX1 antagonist. It was also found that orexin A suppressed the mRNA expression of both type-I and -II receptors for BMPs and increased that of inhibitory Smad6 and Smad7 in granulosa cells. On the other hand, treatments with BMP-6 and -7 suppressed the expression of OX1 and OX2. Collectively, the results indicated that orexin A enhances FSH-induced progesterone production, at least in part, by downregulating BMP signaling in granulosa cells. Thus, a new role of orexin A in facilitating progesterone synthesis and functional interaction between the orexin and BMP systems in granulosa cells were revealed.

Effect of the interaction of metformin and bone morphogenetic proteins on ovarian steroidogenesis by human granulosa cells

In the present study, we studied the effects of metformin and its interactions with the actions of bone morphogenetic proteins (BMPs) on ovarian steroidogenesis. It was revealed that metformin treatment enhanced progesterone production by human granulosa KGN cells and rat primary granulosa cells induced by forskolin and FSH, respectively. In human granulosa cells, it was found that metformin treatment suppressed phosphorylation of Smad1/5/9 activated by BMP-15 compared with that induced by other BMP ligands. Moreover, metformin treatment increased the expression of inhibitory Smad6, but not of that Smad7, in human granulosa cells, while metformin had no significant impact on the expression levels of BMP type-I and -II receptors. Thus, the mechanism by which metformin suppresses BMP-15-induced Smad1/5/9 phosphorylation is likely, at least in part, to be upregulation of inhibitory Smad6 expression in granulosa cells. The results suggest the existence of functional interaction between metformin and BMP signaling, in which metformin enhances progesterone production by downregulating endogenous BMP-15 activity in granulosa cells.

Hypersensitivity pneumonitis caused by a home ultrasonic humidifier contaminated with Candida guilliermondii

We herein report the first documented case of acute hypersensitivity pneumonitis in which Candida guilliermondii was the possible causative organism. A young Japanese woman presented to our hospital with relapsing respiratory symptoms accompanied by high fever. A detailed interview revealed that the onset of the symptoms occurred shortly after using a humidifier in her home. Her symptoms showed spontaneous improvement soon after admission, and an examination of her bronchoalveolar lavage fluid revealed the specific infiltration of inflammatory cells, which predominantly consisted of lymphocytes. Precipitin testing showed a positive reaction to C. guilliermondii, which was isolated from the home humidifier. Repeated history taking is essential for diagnosing occult respiratory disorders.

Diffuse intestinal ganglioneuromatosis showing multiple large bowel ulcers in a patient with neurofibromatosis type 1

A 67-year-old Japanese man with neurofibromatosis type 1 underwent right hemicolectomy owing to abscess formation around the cecum. A pathological analysis revealed diffuse intestinal ganglioneuromatosis in the cecum and colon. Colonoscopy performed eight months after hemicolectomy revealed multiple ulcers throughout the colon and rectum. The colorectal ulcers failed to respond to conservative treatment and ultimately required surgical resection. Diffuse ganglioneuromatosis was observed again in the resected specimen. This report illustrates a rare manifestation of diffuse intestinal ganglioneuromatosis in a patient with neurofibromatosis type 1.

Pulmonary intravascular lymphoma detected by FDG-PET

A 69‐year‐old woman visited our hospital with a 2‐month history of general fatigue, high fever, and dyspnea. Physical examination showed no abnormalities in superficial lymph nodes or respiratory sound. A chest computed tomography scan showed diffuse mild ground‐glass attenuation in bilateral lung fields, whereas FDG‐PET revealed intense uptake of FDG throughout the lung.

Idiopathic adult ileo-colonic intussusception

A 56yearold woman with a 10year history of eating disorders and alcohol dependence was admitted at another hospital for the treatment of emaciation. Her body weight was 54 kg in her 20s. On admission, her body weight was 31 kg and her height was 153 cm (body mass index, 13.2). Intravenous hyperalimentation was initiated; however, liver dysfunction, peripheral edema, and ascites appeared 2 weeks later. As refeeding syndrome was suspected as the cause of her liver dysfunction, calories infused per day were reduced. Subsequently, peripheral edema and ascites worsened. In addition, she experienced abdominal fullness, distention, and nausea after defecation using a suppository and glycerin enema. Four weeks after admission to the hospital, she was referred to our hospital for further investigation and treatment of emaciation, liver dysfunction, ascites, and abdominal symptoms. On physical examination, her abdomen was distended without tenderness or palpable tumors. Her bowel sounds were increased but there were no metallic sounds. Laboratory testing revealed an exacerbating increase of liver enzyme levels: aspartate aminotransferase, 305 U/L; alanine aminotransferase, 634 U/L; alkaline phosphatase, 996 U/L; and γglutamyl transpeptidase, 122 U/L. Contrastenhanced computed tomography (CT) scanning revealed ileocolonic intussusception in which the ileum extended to the hepatic flexure of the ascending colon (Figure 1, arrow). Although initially considered, surgical management was waived because of multiple risks with general anesthesia, such as emaciation and liver damage, and there were no signs of intestinal ischemia. Colonoscopy performed after a highpressure enema with 500 mL water revealed that the intussusception was resolved and the ileal mucosa was reddish and edematous. Endoscopic ultrasonography (Figure 2), video capsule enteroscopy, and CT scanning (Figure 3) performed after the resolution of the intussusception showed only

Endoscopic detection of the gastric lesions of peripheral T-cell lymphoma

An 82-year-old Japanese man presented with a gastric involvement of peripheral T-cell lymphoma, not otherwise specified. Although gastrointestinal lesions were not detected on computed tomography, oesophagogastroduodenoscopy revealed a slight elevation of the gastric mucosa, with changes in mucosal colour and the presence of abnormal microvessels. This led to the prompt detection of gastric involvement in lymphoma. This case highlights the usefulness of detailed observation of the gastric mucosa for the endoscopic detection of gastric involvement of peripheral T-cell lymphoma.

Pheochromocytoma Manifesting Persistent Right Shoulder Pain and Hypochondralgia

We report a 42‐year‐old female who initially complained of sub‐acute onset of right upper quadrant abdominal pain with right shoulder pain. A CT scan incidentally revealed an adrenal tumor, and a final diagnosis of pheochromocytoma was made on the basis of endocrinological examinations. Symptomatically, the pheochromocytoma in our patient mimicked a hepato‐biliary disease by presenting abdominal pain accompanying right shoulder pain that was assumed to be referred pain via the right phrenic nerve. Physicians may need to consider the possibility of pheochromocytoma in patients with abdominal symptoms.