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An 84-year-old woman presented to our hospital with dyspnea on exertion and left back pain. Chest X-ray and chest computed tomography (CT) revealed an irregular pleural mass invading her left chest wall with rib destruction and pleural effusion. CT-guided needle biopsy revealed diffuse large B-cell lymphoma. Low-dose oral etoposide produced a complete response, and she continued oral chemotherapy for one year after the diagnosis and maintained good performance status. We herein report a very rare case of non-pyothorax-associated lymphoma that nonetheless resulted in great recovery.

A 69-year-old man presented with upper airway symptoms, multiple lung nodules and masses, proteinuria and hematuria, and an increased level of proteinase 3 anti-neutrophil cytoplasmic antibody (PR3-ANCA). Granulomatosis with polyangiitis (GPA) was diagnosed by a transbronchial lung biopsy. All of these symptoms were ameliorated and the level of PR3-ANCA declined following treatment with prednisolone and cyclophosphamide. The patient developed a headache 16 months after the onset of symptoms, and contrast-enhanced magnetic resonance imaging showed the thickening of the dura mater, which suggested that hypertrophic pachymeningitis (HP) had developed as a complication of GPA. HP can be a unique complication of GPA at recurrence, and can occur without the relapse of other lesions or an increase in PR3-ANCA level.

We herein report a rare case of acute bilateral renal and splenic infarctions occurring during chemotherapy for lung cancer. A 60-year-old man presented with acute and intensive upper abdominal and back pain during chemotherapy with cisplatin and etoposide for lung cancer. Contrast-enhanced computed tomography (CT) revealed bilateral renal and splenic infarctions. After the administration of unfractionated heparin his pain was relieved with a clearance of the infarctions in the CT findings and a recovery of renal dysfunction. Enhanced coagulation by lung cancer and arterial ischemia by chemotherapy may therefore contribute to the development of these infarctions.

We treated a woman with membranous nephropathy in whom serious nephrotic syndrome (NS) continued even after the introduction of hemodialysis (HD). No response was seen with conservative treatment, including administration of steroids and albumin transfusion and body fluid management with HD. Hypoalbuminemia continued, and management of her general condition was problematic because of the hypotension, edema, pleural and peritoneal effusions. We performed percutaneous renal artery embolization (RAE), voluntary urine output disappeared for a short time, and good clinical course was subsequently seen with sustainable serum albumin levels of around 3 g/dL.

We report an 82-year-old Japanese woman with multiple myeloma (MM). She developed disorientation due to hyperammonemia after melphalan and prednisolone therapy and abruptly died with a rapid clinical course. Karyotypic analysis of bone marrow showed complex abnormalities including a variant Burkitt-type translocation, t(2;8)(p12;q24), but the patient had IgG-lambda type M-proteinemia. Although patients with MM associated with hyperammonemia have been sporadically reported and their prognosis is poor, specific chromosomal abnormalities in the lesion have not been well characterized. It is, therefore, important to accumulate such patients to find a possible relationship between hyperammonemia and chromosomal abnormalities.

A 66-year-old woman with malignant lymphoma became neutropenic during chemotherapy and developed cryptococcemia. After amphotericin B had been commenced, she developed significant hypokalemia and polyuria, though her renal function remained stable. The laboratory findings showed no evidence of renal tubular acidosis. With vigorous water and potassium replacement, amphotericin B had been continued until the cumulative dose reached 2.5 g. After the cessation of amphotericin B, the hypokalemia and polyuria resolved promptly. Based on theses findings, she was diagnosed as nephrogenic diabetes insipidus with hypokalemia and without renal tubular acidosis due to amphotericin B. This complication is usually reversible, and vigorous water and potassium replacement may allow completion of treatment by amphotericin B, though careful monitoring of body water balance and renal function is of importance.

To clarify the characteristics of upper airway muscles under hypoxic condition in obstructive sleep apnea syndrome (OSAS), we performed the isocapnic progressive hypoxia test during wakefulness in 8 controls and 7 OSAS patients. Electromyographic activities were recorded from the genioglossal muscle (EMG(GG)) and diaphragm (EMG(DIA)) with ventilatory variables. Minute EMG (peak integrated EMG x respiratory rate) activity against P(ET)O2 was calculated by exponential equation, and its response slope represented the hypoxic sensitivity of each muscle, slope(GG) and slope(DIA). There was no significant difference between the slopes of OSAS and control. In contrast, the ratio of the two responses, slope(GG)/slope(DIA), was significantly higher in OSAS (1.61 +/- 0.49 SD) than in control (0.98 +/- 0.43). Moreover, the slope(GG)/slope(DIA) ratio was negatively correlated with the ratio of sleep time with SpO2 lower than 90% to total sleep time. We conclude that the neuromuscular compensatory mechanism of upper airway muscles is effectively developed and plays an important role in preventing nocturnal hypoxemia in OSAS.

We prospectively examined the survival rate of 67 chronic obstructive pulmonary disease (COPD) and 74 late sequelae of pulmonary tuberculosis (TB seq) patients to clarify whether nocturnal oxyhemoglobin desaturation (NOD)could be one of the independent factors determining their mortality. The sleep monitoring of arterial oxygen saturation (SpO2) and pulmonary function tests were assessed in all patients at the time of registration. Forty %of COPD and 24%of TB seq died as the direct result of deterioration of chronic respiratory failure during the 7-year observation period. Cox's proportional hazards analysis showed that NOD was an independent prognostic factor in both groups, and this was especially prominent when evaluated in terms of sleep lowest SpO2 in COPD and 85% desaturation time in TB seq. No significant prognostic factor was observed among age, vital capacity percent predicted (%VC), forced expiratory volume in one second (FEV1.0%)and partial pressure of carbon dioxide (PaCO2). We conclude that the degree of NOD can affect mortality in COPD and TB seq.(Internal Medicine 37: 354-359, 1998)

Since obstructive sleep apnea syndrome (OSAS) is often linked with systemic hypertension, we sought to clarify the characteristics of prostanoid metabolism in OSAS. In 7 OSAS patients (apnea-hypopnea index, 51.0 +/- 23.4) and 7 non-snorers as control, nocturnal urine was sampled and analyzed for stable metabolites of prostacyclin (PGI2) and thromboxane A2 (TxA2), [6-keto-PGF1alpha and thromboxane B2 (TxB2)]. The ratio of 6-keto-PGF1alpha to TxB2 was significantly higher in OSAS (2.97 +/- 1.52) than in control (1.38 +/- 0.38). Successful treatment with nasal continuous positive airway pressure (8.3 +/- 1.5 cmH2O) for 3 days caused a significant decrease in mean blood pressure in OSAS. Moreover, the 6-keto-PGF1alpha to TxB2 ratio also significantly decreased to 1.74 +/- 0.58, a level which may not significantly different from control. These results suggest that the production ratio of PGI2 to TxA2 is shifted toward vasodilatation in untreated OSAS. We conclude that the production of prostanoids plays a role in compensating for the systemic hypertension in OSAS.

Thirty-eight patients with late sequelae of pulmonary tuberculosis (TB seq.) were studied to clarify the characteristics of sleep desaturation in comparison with 40 patients with chronic obstructive pulmonary disease (COPD). While awake, the TB seq. group had a lower % VC and a higher PaCO2. In both groups, the sleep lowest SaO2 was positively correlated with the awake SaO2. The regression line between the sleep lowest SaO2 and the awake baseline SaO2 in the TB seq. group was located below that in the COPD group. Awake PaCO2 was negatively related to the sleep lowest SaO2 only in the TB seq. group. These results indicate that the sleep lowest SaO2 values were lower in TB seq. than in COPD patients with the same levels of SaO2 while awake. Sleep studies are necessary to reveal the indication for nocturnal oxygen therapy in TB seq. patients, especially when they are hypercapnic in spite of their good awake oxygenation.