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A 69-year-old woman presented with dyspnea on exertion. Echocardiography showed dilatation and diffuse hypokinesis of the left ventricle. 99mTc-tetrofosmin myocardial SPECT showed moderately reduced uptake in the anteroseptal wall and the inferior wall on the rest images, but was improved on the ATP loading images. 123I-BMIPP myocardial SPECT showed severely reduced uptake in the anterior wall and the inferior wall. These SPECT findings suggested ischemic heart disease rather than dilated cardiomyopathy. Coronary angiography showed no organic stenosis, but diffuse coronary ectasia was noted in three vessels. Intravascular ultrasound revealed remarkable coronary ectasia, with a maximal diameter of 8.2 mm. Coronary flow velocity as measured by Doppler blood flow guide wire was remarkably reduced. Coronary spasms were not provocated by ergonovine loading test. These findings suggested that microvascular thrombi and disturbance of dilatation caused myocardial ischemia in this patient. We treated the patient with ticlopidine and nicorandil. Following treatment left ventricle wall motion, 99mTc-tetrofosmin and 123I-BMIPP myocardial SPECT findings were improved.

We reported a case of a 72-year-old man with chest pain. An electrocardiogram showed ST segment elevation in I, II, III, aVL, aVF and V1-6 leads. 99mTc-tetrofosmin myocardial SPECT showed defect in the anterior, septal, apical and inferior walls. Coronary angiography showed 99% stenosis of the proximal right coronary artery and total occlusion of the midsegment of the left anterior descending coronary artery. Therefore, direct PTCA was performed for each lesion to achieve reperfusion. We didnt's see reperfusion injury during PTCA of the left coronary artery. On the other side, we saw severe reperfusion injury, such as slow-flow, arrhythmia and falling blood pressure during PTCA of the right coronary artery. After four hours, 99mTc-PYP myocardial SPECT showed marked uptake in the apical and inferior walls, and mild uptake in the anterior and posterior walls. After three days, severely-reduced uptake of 99mTc-PYP in the apex was noted, and mild uptake in the mid-portion of the anterior wall and the mid-portion of the inferior wall. Though reperfusion injury was seen, three was mild myocardial uptake of 99mTc-PYP in the area of the right coronary artery. On the other side, despite no reperfusion injury, there showed marked uptake during the acute phase and defect during the subacute phase in the area of the left coronary artery. Wall motion of the left ventricle was normal in the area of the right coronary artery and akinesis was seen on the left. These findings suggest that 99mTc-tetrofosmin and 99mTc-PYP myocardial SPECT are useful for visualization of reperfusion injury during the acute phase and for estimation of function during the chronic phase, better even than electrocardiogram or coronary angiography.

A 26-year-old woman with neurofibromatosis 1 was admitted to our hospital for investigation of prolonged hypertension after toxemia of pregnancy. Plasma renin activity was elevated. From the renogram, stenosis of right renal artery was suspected and we performed renal arteriography, which revealed proximal right renal artery stenosis. The intravascular ultrasound (IVUS) image showed concentric stenosis with intimal and medial hypertrophy, which was iso-echoic and partly high echoic. Percutaneous transluminal renal angioplasty was performed and the lesion was well dilated. After angioplasty, blood pressure normalized in a week. From the clinical course and the IVUS image, we suspected that renal artery stenosis was due to neurofibromatosis 1.

We treated seven refractory or relapsed myeloma patients resistant to conventional chemotherapy with thalidomide. We started thalidomide at 100 mg daily and the dose was increased up to 300 mg if the patient could tolerate it. The patients were evaluated at four weeks and 12 mg of dexamethasone was added for four days when the patient failed to respond to thalidomide treatment. One patient was excluded from the study because of general fatigue. Two of the six patients responded to thalidomide alone and three of the remaining four patients responded to the combination with dexamethasone. The most common adverse effect was sleepiness which was seen in three patients. Two patients showed pancytopenia (Grade 3), constipation and skin eruption. Of the six patients four needed reduction of the thalidomide dose to 200 mg because of adverse effects. Plasma levels of TNF-alpha, IL-6, bFGF and VEGF were measured before and after four weeks. High plasma bFGF levels were seen in responding patients. In conclusion, treatment with thalidomide alone or in combination with dexamethasone is feasible and effective in refractory or relapsed myeloma patients. Further study is required to clarify the role of thalidomide in the therapeutic strategy for multiple myeloma.

A 57-year-old woman was emergently admitted to our hospital because of chest oppression. On examination, blood pressure was 174/96 mmHg, pulse rate was 90/min and coarse crackle and third heart sound were audible. On laboratory data, the levels of LDH and CPK-MB were mildly elevated. Electrocardiogram (ECG) demonstrated elevation of the ST segment in leads I, aVL and V2-V5. 99mTc-tetrofosmin myocardial SPECT (TF) showed severely reduced uptake in the apex and anterior wall. Emergent coronary angiography (CAG) did not show any stenotic lesion. Left ventriculography (LVG), however, demonstrated akinesis of the apex, anterior, and inferior walls, and basal hyperkinesis. On the second hospital day, ECG demonstrated inverted T wave in leads I, aVL and V2-V5. 123I-BMIPP myocardial SPECT (BMIPP) and 123I-MIBG myocardial SPECT (MIBG) were performed on the second and fourth hospital days, respectively. These cardiac images showed severely reduced uptake equally. TF, BMIPP, and MIBG were re-examined on the eighth, tenth, and twelfth hospital days, respectively. MIBG, BMIPP, and TF showed reduced uptake in order of severity. On the fourteenth hospital day, CAG and LVG were re-examined. Coronary vasospasm provocation test was negative using ergonovine and acetylcholine, and LVG did not demonstrated any sign of asynergy. We considered that this case was "Takotsubo" cardiomyopathy and might be caused by microvascular spasm.

We report a patient with myelodysplastic syndrome (MDS) overt leukemia who developed an acute myeloid leukemia (AML) in donor cells shortly after bone marrow transplantation (BMT) from his HLA-matched sibling. Molecular analysis using microsatellite repeats by polymerase chain reaction proved the new leukemia to be of donor cell origin. The patient received chemotherapy with idarubicin and ara-C, but he died due to mucormycosis.

A 66-year-old-man was admitted to our hospital because of chest pain on effort in October 1999. The initial images of 123I-BMIPP myocardial SPECT (BM) showed moderately decreased tracer uptake in the apex and the delayed images revealed redistribution in the apex. Coronary angiography revealed 99% stenosis in the proximal portion of the left anterior descending artery. Since sudden onset anaphylactic shock induced by contrast media developed, so percutaneous transluminal coronary angioplasty was not performed. The patient's symptoms were improved with medical treatment. On BM in March 2000, the initial images indicated slightly reduced uptake in the apico-anteroseptal region and the delayed images revealed mildly redistribution in the same area. BM in September 2000, the initial images showed moderately reduced uptake in the apico-anteroseptal region and the delayed images revealed high washout in the same area. The patient's symptoms markedly deferiorrated in March 2001, and BM initial images revealed slightly reduced uptake in the apico-anteroseptal region and the delayed images revealed redistribution in the same area again. During the clinical course, electrocardiography and 99mTc-tetrofosmin myocardial SPECT revealed no marked changes. We consider that 123I-BMIPP myocardial SPECT is useful in estimating myocardial ischemia.

A 27-year-old man complaining of cough was admitted to our hospital because of a giant mediastinal tumor on the chest radiograph. Chest CT and MRI revealed a giant polycystic mediastinal tumor. Chest radiographs on admission showed left pleural effusion due to perforation of the cyst. Laboratory data showed high serum and pleural fluid concentrations of CA 125, CA 19-9, SLX and others. The mediastinal mass was resected and diagnosed pathologically as a mature teratoma. It is reported that patients with mediastinal teratomas often have pleural fluid as a result of self-digestion by pancreatic enzymes, and some mediastinal teratomas have high serum tumor marker levels. We suspected that the high serum tumor marker levels in our case were caused by the high concentrations of tumor markers in the pleural fluid. We suggest that serum tumor marker levels may be useful in the preoperative differential diagnosis of anterior mediastinal cystic tumors.

We report a case of Mycobacterium abscessus infection complicated with diabetes mellitus. A 38-year-old man with diabetes mellitus as an underlying disease, was admitted to our hospital because of a productive cough. He had had pulmonary tuberculosis two years before. Chest radiography revealed infiltration in both lung apices and chest CT showed a cavitary lesion in the left upper lobe. Gaffky 2 was found on a sputum smear. However, in the examination of PCR on sputum, not only M. tuberculosis but M. avium complex was negative, and repeated cultures of sputum were positive for M. abscessus. On the basis of the diagnosis of an M. abscessus infection, the patient was initially treated with amikacin, imipenem/cilastatin and levofloxacin during hospitalization while receiving insulin for diabetes mellitus. The smear and culture of sputum became negative for Mycobacterium, and the findings of chest radiography and chest CT improved. After discharge, treatment was continued with clarithromycin and levofloxacin. It is considered that the choice of effective drugs and the additional treatment of an underlying disease are very important for the treatment of a Mycobacterium abscessus infection.