[Show abstract][Hide abstract] ABSTRACT: Histological evaluation of a peripheral nerve is often the final diagnostic work-up for a neuropathy of unknown origin, and a distal sensory nerve is usually biopsied. Here, we report the case of a female patient with painful unilateral neuropathy in the upper arm. According to the histological evaluation of the pronator teres motor branch, vasculitis seemed to be the most probable cause of the condition, and steroid therapy improved the patients' symptoms. A biopsy of the motor branch of the pronator teres muscle nerve may be considered a valuable diagnostic option in selected cases with neuropathy affecting the upper limb, when performed in cooperation with neurologists and orthopedic surgeons.
Case Reports in Neurology 05/2014; 6(2):202-6. DOI:10.1159/000365883
[Show abstract][Hide abstract] ABSTRACT: Objective:
Hereditary diffuse leukoencephalopathy with neuroaxonal spheroids (HDLS) is an adult-onset white matter disease that presents clinically with cognitive, mental and motor dysfunction. Several autopsy reports have indicated that the corpus callosum (CC), the largest bundle of white matter, is severely affected in patients with HDLS. The aim of this study was to evaluate corpus callosum atrophy (CCA) quantitatively in HDLS patients.
We assessed CCA in six genetically-proven HDLS patients (HDLS group), in comparison with that observed in 20 patients with vascular dementia (VaD group) and 24 age-matched patients without organic central nervous system (CNS) disease (non-CNS group). Using midsagittal MR images, five measurements of the CC were obtained: the width of the rostrum (aa'), body (bb') and splenium (cc'), the anterior to posterior length (ab) and the maximum height (cd). Next, the corpus callosum index (CCI) was calculated as (aa' + bb' + cc')/ab.
All HDLS patients had white matter lesions in the CC and frontoparietal lobes on the initial MRI scans. Compared with that observed in the VaD and age-matched non-CNS groups, the CCI was significantly decreased in the HDLS group (with VaD group, p<0.01; with non-CNS group, p<0.01).
This study showed significant atrophy of the CC in all HDLS patients on the initial MRI scans obtained 6-36 months after onset. We propose that the early appearance of CCA, frequently accompanied by high-intensity in the genu and/or splenium, on T2 images is an important diagnostic clue to HDLS.
Internal Medicine 01/2014; 53(1):21-7. DOI:10.2169/internalmedicine.53.0863 · 0.90 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: We report a 51-year-old female patient with adult-onset type II citrullinemia (CTLN2) who had a history of pancreatoduodenectomy for duodenal somatostatinoma with metastases to regional lymph nodes at age 49 years, paying special attention to indications for liver transplantation. At age 50 years, she developed hepatic encephalopathy with elevation of plasma ammonia and citrulline levels. A diagnosis of CTLN2 was made by DNA analysis of the SLC25A13 gene and treatment with conservative therapies was begun, including a low-carbohydrate diet and supplementation with arginine and sodium pyruvate. However, despite these treatments, frequent attacks of encephalopathy occurred with markedly elevated plasma ammonia levels. While we were apprehensive regarding the risk of recurrence of somatostatinoma due to immunosuppressive therapy after liver transplantation, the patient was in a critical condition with CTLN2 and it was decided to perform living-donor liver transplantation using a graft obtained from her son. Her postoperative clinical course was uneventful and she has had an active life without recurrence of somatostatinoma for 2 years. This is the first case of CTLN2 with somatostatinoma. As the condition of CTLN2 patients with rapidly progressive courses is often intractable by conservative therapies alone, liver transplantation should be considered even after surgery for malignant tumors in cases with neither metastasis nor recurrence.
Hepatology Research 05/2013; 43(5):563-8. DOI:10.1111/j.1872-034X.2012.01098.x · 2.74 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: We herein report the case of a 41-year-old Japanese man with hereditary diffuse leukoencephalopathy with spheroids (HDLS) who carried the de novo K793T mutation in the colony-stimulating factor 1 receptor gene (CSF1R). He showed a gradual decline of his cognitive and mental functions over the following six months. On brain MRI, a thin corpus callosum with T2- and FLAIR-high signal intensity in the splenium was conspicuous, whereas cerebral deep and periventricular white matter lesions were mild. We propose that a diagnosis of HDLS should be considered in patients with presenile dementia presenting with corpus callosum lesions on MRI, even in cases with a lack of any apparent family history.
Internal Medicine 02/2013; 52(4):503-6. DOI:10.2169/internalmedicine.52.8879 · 0.90 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: We report a patient with primary anti-phospholipid syndrome (APS) who developed pulmonary edema following sudden-onset pain in the left, lower back of the chest. Radiological examinations demonstrated fresh infarction of the left adrenal gland but no obvious thrombi in pulmonary arteries. The patient quickly recovered from pulmonary edema with anti-coagulation therapy alone. Primary APS may have caused adrenal infarction in the patient, leading to transient pulmonary edema via microthrombosis and/or excessive release of catecholamine.
Clinical Medicine Insights: Case Reports 12/2012; 5:163-8. DOI:10.4137/CCRep.S10808
[Show abstract][Hide abstract] ABSTRACT: We report a patient with polyarteritis nodosa (PN) who showed frequent episodes of acute-onset central nervous system (CNS) involvement mimicking relapsing-remitting multiple sclerosis (MS) for 22 years. Long-term use of oral prednisolone successfully avoided recurrence of neurological symptoms. PN can sometimes affect the CNS, and is an important item in the differential diagnosis of neurological manifestations with lesion dissemination in time and space, as seen in MS.
Modern Rheumatology 11/2012; 24(3). DOI:10.1007/s10165-012-0783-x · 2.40 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: We report the first two cases of adult-onset type II citrullinemia (CTLN2) successfully treated by liver transplantation from deceased donors in Japan. One patient was a 34-year-old female, who had suffered from depression since the age of 28 years and developed consciousness disturbance at 34 years old. The other patient was a 41-year-old man who began to experience consciousness disturbance with abnormal behavior at 37 years old. Both patients were first treated with non-surgical therapies, including low-carbohydrate diet, arginine granules and sodium pyruvate. However, their therapeutic efficacy was limited and attacks of encephalopathy occurred frequently with elevation of plasma ammonia despite treatment. While both patients and their families desired liver transplantation, no candidate donors for live-donor liver transplantation were available. Fortunately, within a relatively short period after enrollment for liver transplant from deceased donors in Japan (13 and 43 days, respectively), they underwent cadaveric liver transplantation. The clinical courses after the operation were uneventful in both cases and no attacks of hepatic encephalopathy have occurred. Although there have been no reports of good therapies for CTLN2 patients with resistance to non-surgical therapies and no live-donor candidates, our observations indicate that cadaveric liver transplantation can be a promising therapeutic option for CTLN2 patients.
Hepatology Research 09/2012; 42(9):934-9. DOI:10.1111/j.1872-034X.2012.00992.x · 2.74 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Neuralgic amyotrophy (NA) is a distinct peripheral nervous system disorder characterized by attacks of acute neuropathic pain and rapid multifocal weakness and atrophy unilaterally in the upper limb. The current hypothesis is that the episodes are caused by an immune-mediated response to the brachial plexus, however, therapeutic strategies for NA have not been well established.
We retrospectively reviewed 15 case series of NA; 10 of the 15 patients received intravenous immunoglobulin (IVIg) with methylprednisolone pulse therapy (MPPT) and 9 of these 0 patients showed clinical improvement of motor impairment.
Our clinical observations do not contradict the possibility that IVIg with MPPT may be one of the potential therapeutics for NA, however the efficacy remains to be established. Further confirmatory trials are needed in patients with various clinical severities and phases of NA. Further basic research and confirmatory trials should be performed to survey the efficacy of such immunomodulation therapy for NA.
Internal Medicine 06/2012; 51(12):1493-500. DOI:10.2169/internalmedicine.51.7049 · 0.90 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Matrix metalloproteases (MMPs) are a family of endopeptidases classified into subgroups based on substrate preference in normal physiological processes such as embryonic development and tissue remodeling, as well as in various disease processes via degradation of extracellular matrix components. Among the MMPs, MMP-9 and MMP-2 have been reported to be up-regulated in skeletal muscles in the lethal X-linked muscle disorder Duchenne muscular dystrophy (DMD), which is caused by loss of dystrophin. A recent study showed that deletion of the MMP9 gene in mdx, a mouse model for DMD, improved skeletal muscle pathology and function; however, the role of MMP-2 in the dystrophin-deficient muscle is not well known. In this study, we aimed at verifying the role of MMP-2 in the dystrophin-deficient muscle by using mdx mice with genetic ablation of MMP-2 (mdx/MMP-2(-/-)). We found impairment of regenerated muscle fiber growth with reduction of angiogenesis in mdx/MMP-2(-/-) mice at 3 months of age. Expression of vascular endothelial growth factor-A (VEGF-A), an important angiogenesis-related factor, decreased in mdx/MMP-2(-/-) mice at 3 months of age. MMP-2 had not a critical role in the degradation of dystrophin-glycoprotein complex (DGC) components such as β-dystroglycan and β-sarcoglycan in the regeneration process of the dystrophic muscle. Accordingly, MMP-2 may be essential for growth of regenerated muscle fibers through VEGF-associated angiogenesis in the dystrophin-deficient skeletal muscle.
Human Molecular Genetics 02/2011; 20(9):1787-99. DOI:10.1093/hmg/ddr062 · 6.39 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Some patients with citrin deficiency caused by SLC25A13 gene mutations develop adult-onset type II citrullinemia (CTLN2) with hepatic encephalopathy. A recent nutritional survey of 18 citrin-deficient subjects (age 1-33 y) confirmed a marked decrease in carbohydrate intake compared to an age-matched general Japanese population. However, a quantitative understanding of food intake in CTLN2 patients remains unclear, although qualitative dietary information has been reported. In order to elucidate the characteristics of daily nutrition of CTLN2 patients, the food intake of 5 male patients (age 39-52 y) was investigated in detail by the Food Frequency Questionnaire. In the present survey, the mean energy ratio of protein : fat : carbohydrate (PFC ratio) of the 5 patients was 19±3% : 44±5% : 37±4%, which was almost identical to previously reported data in younger citrin-deficient subjects (19±2% : 44±5% : 37±7%). Cereal intake was especially low in all CTLN2 patients at 309±33 g/d (56% of control), compared to that in an age-matched general Japanese population (553±197 g/d). Additionally, CTLN2 patients preferred high fat and protein foods. Commonly, fat intake declines with age in the general Japanese population, but this tendency was not observed in the 5 CTLN2 patients. The present results suggest that intakes of low-carbohydrate, high-protein and high-fat food was characteristic the 5 CTLN2 patients surveyed, as has been previously reported in younger citrin-deficient subjects, and that the PFC ratio may not be influenced by age or CTLN2-onset.
Journal of Nutritional Science and Vitaminology 01/2011; 57(3):239-45. DOI:10.3177/jnsv.57.239 · 0.83 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: We report a patient with rheumatoid arthritis (RA) who developed leukoencephalopathy while being treated with low-dose methotrexate (MTX). She suddenly developed loss of recent memory and left homonymous hemianopsia ascribable to the bilateral but right-predominant occipitotemporal lesions. Intravenous administration of dexamethasone and cessation of MTX quickly relieved her clinical symptoms. Low-dose MTX-induced leukoencephalopathy is a rare complication in RA, but is important with regard to the possibility of serious neurological sequellae.
Internal Medicine 01/2011; 50(19):2219-22. DOI:10.2169/internalmedicine.50.5552 · 0.90 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: We report a 70-year-old man with a 5-year history of Raynaud's phenomenon and slow progression of weight loss, easy fatigability, muscle weakness, skin sclerosis, and dropped head sign. The patient was assumed to have motor neuron disease by his attending physician, and was referred to our hospital. Physical examination showed skin sclerosis on the fingers, hands, forearms, face, and neck. Neurological examination showed advanced systemic muscle atrophy and weakness, especially in the neck, tongue, and proximal limb muscles. Fasciculations were not observed in these involved muscles. Deep tendon reflexes were hypoactive and pathological reflexes were negative. Sensory disturbance was absent. Laboratory tests showed moderately elevated serum creatine kinase level, and increased serum antinuclear antibody titer (1:5120 with a nucleolar pattern). Needle electromyography showed a typical myogenic pattern in proximal muscles. The patient was diagnosed as having systemic sclerosis (SSc) with SSc-associated myopathy. Severe systemic muscle involvements, including dropped head sign and tongue atrophy, are rare manifestations in patients with SSc-associated myopathy. Our observations suggest that it is essential to pay attention to the dermatological findings of SSc in differential diagnosis of patients with muscular atrophy.
[Show abstract][Hide abstract] ABSTRACT: Citrin deficiency caused by SLC25A13 gene mutations develops into adult-onset type II citrullinemia (CTLN2) presenting with hepatic encephalopathy. Recent studies have suggested that excessive loading of carbohydrates is harmful in citrin-deficient individuals. Here we report a CTLN2 patient who showed further deterioration of encephalopathy after the employment of conventional low-protein diet therapy for chronic liver failure. Owing to the high carbohydrate content, the conventional low-protein diet therapy should be avoided in patients with hepatic encephalopathy associated with citrin deficiency. In addition, our observation may suggest that carbohydrate-restricted diet in which the content of carbohydrate is below 50% of daily energy intake can have therapeutic efficacy in CTLN2 patients.
Internal Medicine 01/2010; 49(3):243-7. DOI:10.2169/internalmedicine.49.2712 · 0.90 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: We report a patient with systemic lupus erythematosus (SLE) who showed periodic peritonitis with spontaneous remission. She showed compound heterozygous mutations in the MEFV gene, leading to the diagnosis of familial Mediterranean fever (FMF). Oral colchicine successfully reduced the severity and frequency of her peritonitis. SLE occasionally manifests abdominal symptoms, but in cases with periodic peritonitis, associated FMF should be considered as a possible cause.
Internal Medicine 01/2010; 49(20):2259-62. DOI:10.2169/internalmedicine.49.4043 · 0.90 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: We describe a consanguineous family that had progressive myopathy with rimmed vacuole (RV) formation and amyloid deposition. Patient 1 is a 71-year-old woman with muscle atrophy in the lumbar girdle and lower extremities. Patient 2 is a 40-year-old man (the son of Patient 1) with fatty changes in the biceps femoris muscles. Muscle biopsies revealed myopathic and neurogenic degeneration with RV, necrotic fibers, and interstitial amyloid deposition. Amyloid deposition was detected only in the muscle tissue.
[Show abstract][Hide abstract] ABSTRACT: Deletion of exons 45-55 (del45-55) in the Duchenne muscular dystrophy gene (DMD) has gained particular interest in the field of molecular therapy, because it causes a milder phenotype than DMD, and therefore, may represent a good candidate for the goal of a multiple exon-skipping strategy. We have precisely characterized deletion breakpoints in three patients with del45-55 in DMD. Two of them were young adult males of the X-linked dilated cardiomyopathy phenotype, and the third patient revealed the mild Becker muscular dystrophy phenotype of late onset. The deletion breakpoints differed among patients. The deletion started at nt 226 604, 231 518, 117 284 in intron 44, and ended at nt 64 994, 59 314, 71 806 in intron 55, respectively. Deletion junctions showed no significant homology between the sequences adjacent to the distal and proximal end joints in these patients. Deletion breakpoints were not primarily associated with any particular sequence element, or with a matrix attachment region. However, there were several palindromic sequences and short tandem repeats at or near the breakpoints. These sequences, with a marked propensity to form secondary DNA structure intermediates, may predispose local DNA to breakage and intragenic recombination in these patients.
Journal of Human Genetics 02/2009; 54(2):127-30. DOI:10.1038/jhg.2008.8 · 2.46 Impact Factor