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Background We report a case of invasive sinus aspergillosis that extended to the orbital cavity and cavernous sinus and was improved by treatment with micafungin and itraconazole. Case report A 83-year-old woman was referred to our hospital because of headache and impaired of eye movement on the right side. Physical examination revealed impaired function of cranial nerves, II, II, IV, and VI on the right side. MRI showed evidence of inflammation of the right sphenoid sinus and ethmoidal sinus and an enhancing mass in the right cavernous sinus and orbit. Because a culture of a specimen from the right sphenoid sinus extracted during endoscopic sinus surgery, yielede Aspergillus fumigatus, a diagnosed of invasive sinus aspergillosis complicated by cavernous sinus symdrome and orbital apex symdrome was made. It was difficult to completely remove the mass in the sinuses surgically and drug therapy with micafungin was started and then itraconazole was added. The clinical manifestations and the impaired function of cranial nerves II, III, IV, and VI improved, and MRI showed regression of the mass in the sinuses temporary in response to drug therapy. Conclusion Invasive sinus aspergillosis often progresses rapidly in the absence of surgery. Our case is valuable, because invasive sinus aspergillosis was improved by drug therapy alone, and combined treatment with micafungin and itraconazole was effective.

A 61-year-old man with hypertension had developed exertional dyspnea for 2 years. His symptom got worse with fever and wet cough 4months prior to admission (PTA), and inspiratory pain on his right chest 3 months PTA. He was suspected of having an atypical pneumonia or a tuberculosis on CT. Enhanced chest CT showed large mural defects in right main pulmonary artery, clearly delineated by contrast medium.He was diagnosed as having a pulmonary embolism and received anticoagulation therapy with heparin followed by warfarin. Despite 1 week of warfarin therapy, he remained symptomatic with no change in the pulmonary artery filling defects on repeated enhanced CT.Pulmonary artery sarcoma, or a metastatic tumor were suspected of by its time course and accompanying symptoms and signs of fever, secondary anemia, and weight loss. Increased uptake of FDG in the affected pulmonary artery indicated that pulmonary artery sarcoma was most likely.Aspiration cytology and needle biopsy through pulmonary artery catheter revealed malignant cells with results of CD31(-), CD34(-), D2-40(+),α-Actin(-), and AE1/AE3(+), consistent with pulmonary artery sarcoma which was not able to be specified further.It was out of operative indication because of distant metastasis in his lungs. Therefore, he received weekly Paclitaxel(45mg/m2) + Carboplatin(AUC 2)concurrent with TRT 60Gy/30Fr in order to mainly control intra-arterial mass. However, we discontinued it at 6courses because of neutropenia(Gr3) and development and progression of non-tuberculosis mycobacterium infection. He was also intolerable to pazopanib due to many side effects of increasing in the liver enzymes(Gr1), hypertension(Gr3), anorexia(Gr3), diarrhea(Gr3), nausea(Gr3) and NTM exacerbation. On the other hand, his primary and metastatic lesions have a tendency to decrease in size in comparison with one before chemotherapy. We will report this case with literature review in terms of diagnostic difficulty of pulmonary artery sarcoma.

We present three cases of intracranial hemorrhage with metastasis of gastric cancer to the bone/bone marrow. Case1: A 62-year-old man with history of distal gastrectomy 15 years ago was pointed out to have elevated ALP level and diffuse increased uptake of bone scintigraphy, which turned out to be a recurrence of diffuse metastases to bone and bone marrow confirmed by bone marrow biopsy. After partially successful treatment of chemotherapy with 6 cycles of TS-1 + CDDP, he developed an acute subdural hematoma, complicated by DIC. Craniotomy for removal of hematoma was performed. However, he was died of brain bleeding 12 months after diagnosis of recurrence. Case2: A 60-year-old man underwent subtotal gastrectomy 9 years ago. Similarly, diffuse bone and bone marrow metastasis was confirmed by bone marrow biopsy with trigger of elevated ALP level and diffuse increased uptake of bone scintigraphy. After chemotherapy with TS-1 + CDDP as 1st line and DTX as 2nd line was performed, he also developed and died of subdural hematoma with DIC 22months after diagnosis of recurrence. Case3: A 65-year-old woman with rheumatoid arthritis was pointed out to have low platelet and elevation of LDH and ALP in her regular visits. Endoscope examinations and imaging studies showed gastric cancer with multiple metastases to bone and bone marrow complicated by DIC. Although chemotherapy with TS-1 and blood transfusion was performed, she developed an acute subdural hematoma and received craniotomy for removal of hematoma. However she died of brain rebleeding 4 months after initial diagnosis. The following things are quite interesting in these 3 cases. 1) The former 2cases recurred with bone and bone marrow metastasis after long interval. 2) All cases developed bone and bone marrow metastasis complicated by fatal intracranial hemorrhage without obvious bleeding tendencies in other parts of body. We will discuss those issues with literature review.

Rapid amelioration of hypercholesterolemia by LDL apheresis (LDL-A) was performed for long-standing nephrotic syndrome (NS) with hyperlipidemia due to focal segmental glomerulosclerosis (FGS) and the clinical data and prognosis were compared between LDL-A-treated and nontreated groups. Seventeen steroid-resistant NS patients treated with LDL-A (LDL-A group) and 10 NS patients treated with steroids only (steroid-monotherapy (SM) group) were compared. Serum cholesterol and phospholipid levels were significantly lowered only in the LDL-A group (p < 0.01, respectively). The LDL-A group showed a significant decrease of urinary protein (UP, p < 0.01) and increase of serum albumin (p < 0.05). Average time needed to achieve a decrease of UP to less than nephrotic range (< 3.5 g/day) was significantly shorter in the LDL-A group than in the SM group (p < 0.01). Although this is not a prospective study, it is highly expected that a rapid improvement of hypercholesterolemia by LDL-A in steroid-resistant NS will provide more rapid relief from NS than steroid therapy alone.

A 57-year-old woman with Crow-Fukase syndrome presented thiamine deficiency and pulmonary hypertension of unknown etiology. After oral administration of prednisolone and thiamine, echocardiogram showed marked improvement of the pulmonary hypertension. To our knowledge, this is the first case of this syndrome associated with thiamine deficiency and precapillary pulmonary hypertension, which may play a role in the pathogenesis of polyneuropathy and heart failure of this syndrome.

Prosthetic graft infection is difficult to diagnose early, and hence, is associated with high mortality and morbidity rates. A 63-year-old man who had undergone surgical prosthetic replacement for an inflammatory thoracic aortic aneurysm 10 months previously visited our emergency room, complaining of chills, shivering, frequent vomiting, and back pain. He was diagnosed with severe sepsis, and a blood culture detected Streptococcus anginosus and Prevotella oralis. Repeated contrast-enhanced computed tomography (CT) scans of his chest revealed ectopic gas around the graft, and esophagogastroduodenoscopy revealed esophageal perforations at several sites. We therefore diagnosed him with aortic prosthetic graft infection accompanied with esophagomediastinal fistulas. He received medical treatment and three operations and recovered from the infection. This is a rare case of aortic prosthetic graft infection accompanied with esophagomediastinal fistulas, and we conclude that repeated CT is useful for identifying the primary infection site and invasion route in patients with suspected aortic prosthetic graft infection.