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An 80-year-old woman had developed a slight fever and loss of appetite since October 20XX. In November of the same year, the patient visited our hospital. Peripheral blood tests revealed the presence of atypical lymphocytes and a significant increase in sIL-2R. Tests of bone marrow aspiration samples showed the infiltration of small lymphocytes positive for CD19, CD20, CD23, and lambda. Therefore, a diagnosis of small lymphocytic lymphoma(SLL)was made. A complex karyotype including -X and del(13q)was observed in 19/20. Additionally, an enlarged spleen and retroperitoneal tumors were observed. As a result of 3 courses of fludarabine plus rituximab therapy, atypical lymphocytes were no longer observed in the peripheral blood and the enlarged spleen decreased in size. However, the retroperitoneal tumors could not be reduced. Consequently, a needle biopsy from the same area was performed in February 20XX+1, and a diagnosis of diffuse large B-cell lymphoma(DLBCL)was made. Because massive infiltration of CD23-negative lymphocytes was observed in the bone marrow, it was suggested that chronic lymphocytic leukemia(CLL)had transformed into DLBCL. Following 4 courses of CHOP therapy, the retroperitoneal tumors were reduced. In cases where -X is a microclone, the mutation is often age-related. However, in cases of advanced chronogenesis, as occurred in this patient, a correlation with hematopoietic tumors is arguable. Moreover, cases of CLL with -X have been reported to be related to de(l 13q). Our results strongly suggest that -X with del(13q)may be a clonal expansion in CLL/SLL.

(Introduction)HoLEP's role in the surgical management of benign prostatic hyperplasia (BPH) is steadily growing. In this study, a questionnaire containing questions about perioperative management was submitted to HoLEP surgeons to help establish standard surgical training procedures. (Methods)We sent a comprehensive 17 questionnaires on HoLEP procedures to 18 surgeons. The questionnaire asked, "Which method are you using, the 1-LOBE or 3-LOBE method?", "What educational methods are being used for surgeons?", "How long is the catheter insertion period after HoLEP?", and "What is the most difficult problem encountered in surgical HoLEP education and what aspect of training is the most emphasized?" (Results)Sixteen (88.9%) surgeons answered these questionnaires. Five surgeons reported using the one lobe method, five surgeons reported using the three lobe method, and four surgeons answered that it depends on the case. Regarding educational methods, the main answer was that it is important to evaluate pre-HoLEP imaging tests such as MRI and cystoscopy and to simulate surgery for education. Regarding the postoperative catheter insertion period, 1 day: 1 surgeon, 2 days: 9 surgeons, 3 days: 3 surgeons, 4 days or more: 1 surgeon. The most important thing reported for surgical education was to help beginners understand the characteristics of lasers, including direction, distance to prostate tissue, and adenoma removal. (Conclusions)The surgeons' responses clearly indicated some differences in practices between institutions. More detailed data from these results will provide a step towards designing standardized surgical and educational protocols for HoLEP.

We report a 77-year-old Japanese man with idiopathic thrombocytopenic purpura (ITP) which developed into chronic myelogenous leukemia (CML) during treatment with eltrombopag, a thrombopoetin (TPO) receptor agonist, because the disease was refractory to prednisolone. Eltrombopag can induce a good reaction in terms of the platelet count. However, CML in the chronic phase developed in about 19 months in our present case. Dasatinib was administered because he had diabetes. However, a blastic crisis immediately occurred. He died despite switching to Nilotinib. Recently, the occurrence of myelofibrosis and hematological malignancies due to long-term use of TPO receptor agonists has become a concern. This is the first report of a TPO receptor agonist possibly contributing to CML onset and crisis.

A 69-year-old male was admitted to our hospital for high-grade-fever and body weight loss lasting for a few months. In a previous hospital, extensive laboratory examinations and imaging modalities had failed to establish the origin of the fever. On admission he showed mild anemia, and elevated LDH and CRP, together with a high sIL-2R level, suggesting a possibility of lymphoid malignancy without nodal or solid organ involvements, in particular, intravascular large B-cell lymphoma(IVLBCL). A bone marrow biopsy revealed no abnormal findings except minimal hemophagocytosis. A random skin biopsy was then performed, though no detectable skin lesion was seen. The histological results of the skin materials clearly showed a prominent intravascular large lymphoid cell proliferation with a phenotype of CD20+, CD79a+, CD3- and CD5- in the small vessels. On the basis of these findings, a diagnosis of IVLBCL was established and the patient was treated with(R-)CHOP regimen immediately, which resulted in complete remission following two courses of chemotherapy. Difficulties often arise in the diagnosis of IVLBCL when suspicious lesions suitable for biopsy are lacking. Random skin biopsy would therefore be a useful tool if less invasive measures fail.

Since the progression of chronic lymphocytic leukemia(CLL)is long and requires lengthy primary disease management, the risk of double primary cancers and secondary cancer due to treatment has become an issue in western countries with a high incidence of CLL. However, the coexistence with chronic myeloid leukemia(CML)is rare even in the West, and no cases have been reported in Japan. At this time, we would like to report a rare case of CML coexisting during the progression of CLL. The patient was a 68-year-old woman. As she had entered the advanced stage of B-cell chronic lymphocytic leukemia(B-CLL), fludarabine, a purine analog agent, was administered. Two years later, a high-granulocyte dominant white blood cell count began to appear. BCR/ABL analysis by FISH was 97. 6%positive, and the chromosomal test was t(9:22)(q34:q11), so CML was diagnosed. Coexistence of CML in CLL can mainly be classified into three types; CML preceding CLL, CLL preceding CML, and simultaneous occurrence, and the most common, as in this case, long progression CLL preceding CML. At this time, we performed a mainly bibliographical consideration according to the main occurrence type, including the possibility of secondary CML due to fludarabine.

Reverse transcription-loop-mediated isothermal amplification (RT-LAMP) assay we developed detects novel influenza A (H1N1) of swine origin and seasonal influenza A (H1N1 and H3N2) viruses. Individual primer sets targeting the HA gene for novel H1N1, H1N1, and H3N2 were newly designed to specifically detect these subtypes. No cross-reactions occurred among novel H1N1, H1N1, and H3N2, and 7 respiratory viruses-influenza B virus, influenza C virus, adenovirus, respiratory syncytial virus, metapneumovirus, parainfluenza virus, and rhinovirus-had no reaction to 3 RT-LAMP assays. RT-LAMP is assayed at 63 degrees C for 40 min. In our RT-LAMP assay, Eriochrome Black T was added to the reaction mixture as an amplification indicator to detect virus genomes without using real-time turbidimetry. Positive reactions were indicated in blue and negative reactions remained purple. Of 139 samples from suspected novel H1N1 subjects tested by both RT-LAMP and real-time RT-PCR assay, 110 were positive in both assays. Two samples with low copy numbers were positive only in real-time RT-PCR assay. Of 27 novel negative H1N1 samples, 4 were positive for H3N2 on viral isolation and conventional RT-PCR assay. RT-LAMP assay for detecting H3N2 obtained the same findings. Our RT-LAMP assay is thus potentially useful in rapidly detecting influenza A virus such as novel H1N1, H1N1, and H3N2.

The sensitivity of rapid diagnostic kits to influenza B is lower than to influenza A. The cause-poor performance of the kit or the scarcity of viruses in type B specimens-has yet to be clarified. Using real-time PCR, we measured the amount of influenza viruses with nasopharyngeal aspirate fluid previously identified by virus isolation culture and passing the rapid diagnosis test by four types of kits, including the ESPLINE Influenza A&B-N (Fujirebio Corp., Japan). We classified the results of virus isolation and rapid diagnosis tests into three groups and examined them: group 1 (12 specimens, influenza B, all negative in tests using four types of kits); group 2 (57 specimens, influenza B, all positive in tests); and group 3 (36 specimens, AH3, all positive in tests). The average amount of viruses in group 1 (6.60 +/- 0.81 log10copies/mL) was significantly lower (p<0.0001) than that in group 2 (8.51 +/- 0.57 log10copies/mL) or group 3 (8.72 +/- 0.63 log10copies/mL). No significant difference was seen in the amount of viruses between groups 2 and 3. We concluded that the cause of low sensitivity in rapid diagnostic kits to influenza B are attributable to the scarcity of viruses in the specimen.

In the 2004/05 influenza season there were epidemics of influenza caused by several types of viruses (type B and A (H3) viruses, and type B, A (H3), and A (H1) viruses) in many areas of Japan. In such epidemics a single individual could be co-infected with several influenza viruses. From February to March in 2005, we examined 15 patients who were positive for influenza type A and B viruses when tested with a rapid diagnostic kit. The type A (H3) and B influenza virus genes were successfully amplified by RT-PCR in 10 of the 15 patients, confirming that they were co-infected with type A (H3) and B viruses. The type A (H1) and B virus genes were successfully amplified in another patient, confirming that the patient was co-infected with type A (H1) and B viruses. By contrast, 2 patients were clearly positive for type A and B viruses according to the rapid diagnostic kit, but positive for type B virus alone by RT-PCR. No influenza virus genes were detected by RT-PCR in the remaining 2 patients. To isolate one type from a mixture of two different types of influenza viruses in a specimen, we neutralized one of the types with type-specific antiserum, and isolated the other with MDCK (+) cells. The results obtained by virus isolation were identical to those obtained by RT-PCR. Influenza viruses corresponding to the results of RT-PCR were isolated from 9 of the 11 patients in which isolation was attempted. No viruses were isolated from the 2 patients in whom no virus genes were detectable by RT-PCR. Based on these results we concluded that 11 of 15 patients who were positive for type A and B viruses according to the rapid diagnostic kit were co-infected with type A (H3) or A (H1) and B virus. When several types of influenza viruses are prevalent, as in the 2004/05 influenza season, the possibility of a patient being co-infected with more than one type of influenza virus should be considered.

We compared the usefulness of 4 rapid influenza diagnostic 1-device kits using immunochromatography, which facilitate type differentiation, i.e. ESPLINE Influenza A&B-N (Fujirebio Corp., Japan: ESPLINE), POCTEM INFLUENZA A/B (Sysmex Corp., Japan: POCTEM), Quick Vue Rapid SP influ (Quidel Corp., U.S.A.: Quick Vue), and Capilia Flu A + B (TAUNS Corp., Japan: Capilia), in 278 children in whom influenza infection was suspected in 2004 and 2005. Nasopharyngeal aspirates were diluted for virus isolation and residual samples were centrifuged. Using the supernatant, we conducted rapid diagnosis testing. Influenza virus AH3 was isolated from 40 children, and influenza B virus from 163. Of the 40 children, the sensitivity and specificity of ESPLINE, POCTEM, Quick Vue, and Capilia were 100%/100%, 95%/100%, 98%/96%, and 98%/96%. In the 163 children, the sensitivity and specificity were 89%/100%, 87%/100%, 88%/97%, and 86%/98%. ESPLINE showed the highest sensitivity and specificity to influenza viruses AH3 and B. All kits were less sensitive to influenza B virus than to influenza A virus, however. The specificity of Quick Vue and Capilia was low; so these kits must be improved.

We discussed the clinical features of 5 Japanese encephalitis (JE) cases which we experienced in 2002. Today there are few opportunities for a clinician to see JE patients. Until the 1950s, the number of JE patients was more than 2000 in Japan, but the annual cases of JE are decreasing remarkably due to the extermination of mosquitoes, thorough vaccination and improvement of environmental sanitation. However, even today the disease still has a high fatality rate. In fact 4 in 5 cases we experienced had poor prognosis and one of them resulted in death despite the relatively early diagnosis. It shows the difficulty of diagnosis and treatment. When we see elderly patients with high fever, headache, and impaired consciousness in late summer and autumn, the important thing is to recognize the possibility of JE. Moreover it turned out that brain MRI and detecting serologic JE virus antibodies was very helpful for diagnosis and treatment. Nowadays we clinicians tend to consider JE as a disease of the past in Japan, however, this experience taught us that it is necessary for us to study JE again and to continue educating the public about it.

Echocardiographic findings, clinical features, and pathophysiology of mitral and aortic valve aneurysms were evaluated in four patients with pathologically proven aneurysms of the mitral and/or aortic valves associated with infective endocarditis. These four were selected from 20 patients hospitalized in our institute from April 1990 to May 1995 because of infective endocarditis. All four patients had received repeated, inadequate antibiotic treatments at other medical institutions prior to admission, and underwent surgical repair because of acute hemodynamic exacerbation associated with aneurysmal perforation. Six aneurysms (three mitral and three aortic valve aneurysms) were detected before surgery, including two by transthoracic echocardiography and four by transesophageal echocardiography. The echocardiographic findings typical of aortic valve aneurysm were: ringed echo at the level of the aortic annulus in the short-axis view; turbulent flow within the ringed echo; and dome formation of the aortic valve that persisted throughout the cardiac cycle. All mitral valve aneurysms were true aneurysms without active inflammatory changes or significant destructive lesions, and were associated with severe infective aortic regurgitation. Histologic examination of the aortic valve in these patients showed active inflammation and extensive destruction, suggesting that these valves were the primary focus of infection. One patient had an aortic valve aneurysm without apparent mitral involvement, indicating that another mechanism had mediated aneurysmal formation. We conclude that: diagnosis of mitral or aortic valve aneurysms in patients with infective endocarditis has important therapeutic implications, and therefore, transesophageal echocardiographic examination should be done in such patients: there are three key echocardiographically diagnostic findings of aortic valve aneurysm as mentioned above; and several unknown factors may contribute to aneurysmal formation of the mitral or aortic valve in patients with infective endocarditis.

Xanthogranulomatous pyelonephritis (XGP) is an uncommon form of granulomatous inflammation characterized by destruction and replacement of the renal parenchyma by masses of lipid-laden macrophages. We report the first case of the pyonephrotic type of XGP in which Magnetic resonance imaging (MRI) was used in Japan, and summarize the clinical characteristics of 163 cases with XGP in the Japanese literature for age, sex, laboratory data, preoperative diagnosis and operation. A 56-year-old female was admitted with left flank pain. Left nephrectomy was performed following diagnosis of XGP by computed tomography (CT) and MRI. Histopathological findings confirmed the diagnosis of XGP. Furthermore, we evaluated the MR images in XGP. MR images correlated well with the CT images showing an enlarged multiloculated kidney. The internal portion of the loculated areas were of intermediate intensity on T1-weighted images, and became very intense on the T2-weighted sequences, indicating a long T2. MRI appears to be of value in the investigation of renal mass lesions.

Electrocardiographic features of apical hypertrophic cardiomyopathy are high QRS voltage and giant negative T waves greater than 10 mm in left precordial leads. We analyzed thirty patients with apical hypertrophic cardiomyopathy to clarify the correlation between left ventricular (LV) wall thickness and the depth of negative T waves. LV anterior wall thickness was measured by the left ventriculogram (LVG) in the RAO projection. LV posterior wall and septal thickness were measured by echocardiograms recorded from the left sternal border. THA and THM were defined as apical thickness and mid ventricular wall thickness, respectively. The results were as follows: LVG disclosed that the depth of negative T waves in apical hypertrophic cardiomyopathy was significantly related to the absolute thickness of apical segment itself rather than the difference in the distribution of thickness from the basal to apical segment of the left ventricle. This results support the clinical observation that giant negative T waves in some cases are associated with diffuse hypertrophy of the LV without a spade like configuration in LVG. Results of the echocardiographic analysis, however, revealed that the depth of negative T waves had no relation to the distribution of left ventricular hypertrophy. This is partly because of unsatisfied and difficult recordings and measurements of the true LV apical segment by echocardiography. The presence of both high QRS voltage and giant negative T waves is indispensable for the diagnosis of apical hypertrophy.