Fournier's gangrene (FG) is rapidly progressing acute gangrenous infection of the anorectal and urogenital area. FG needs precocious diagnosis and aggressive treatment with the use of wide spectrum antibioticus and surgical debridement. In our case, a 91-year-old Japanese female who had rehabilitation after treatment of pneumonia and her past history was rheumatoid arthritis treated with steroid and chronic heart failure. Her activities of daily living was bedridden with dementia. Necrotic skin was observed in urogenital and anorectal area and skin redness enlarged to the hip with high fever. Surgical debridement was performed. Both Peptostreptococcus Sp. and Fusobacterium Sp. was cultured from resected necrotic tissue. We used antibioticus, PAPM and PIPC, which had sensitivity for them. But unfortunately, disseminated intravascular coagulation occurred after 4th day of operation, and finally she died after 10th day of operation. We discussed the treatment for FG in patient with complication. J. Med. Invest. 58: 255-258, August, 2011.

Acute appendicitis often presents as right lower quadrant (RLQ) pain, severe tenderness at the point of McBurny or Lanz, and Blumberg's sign. Scrotal events with appendicitis are very rare. In our case, a 63-year-old Japanese man presented with severe RLQ pain and high fever. Physical examination revealed severe tenderness (including both points of McBurny and Lanz) and Blumberg's sign. The scrotum was slightly swollen and showed local heat with severe testicular pain. Abdominal computed tomography revealed ascites in a pelvic space and the right side of the spermatic cord was swollen. Emergency operation was performed and the final diagnosis was catarrhal appendicitis and acute epididymitis. This is the first report of acute appendicitis concomitant with acute epididymitis. J. Med. Invest. 58: 252-254, August, 2011.

A large toxin complex (L-TC) produced by Clostridium botulinum is composed of neurotoxin (BoNT), non-toxic non-hemagglutinin (NTNHA) and hemagglutinin subcomponents (HA-70,-33 and -17). In animal botulism, BoNT or L-TC is internalized by intestinal epithelial cells. Previous studies showed that L-TC binds to intestinal cells via sugar chains on the cell surface, but the role of toxin binding to sugar chains in the toxin absorption from intestine is unclear. To clarify whether the toxin binding to sugar chains on intestinal cell surface leads to its transcytosis across the cells, we examined binding and permeation of BoNT and L-TC of C. botulinum serotype D strain 4947 to the rat intestinal epithelial cell line IEC-6 in semi-permeable filters in Transwell systems. Both BoNT and L-TC bound to and permeated the cell monolayers, with L-TC showing greater binding and permeation. In addition, both binding and permeation of toxins were potently inhibited by N-acetyl neuraminic acid in the cell culture medium or by treatment of the cells with neuraminidase. However, neither galactose, lactose nor N-acetyl galactosamine inhibited binding or permeation of toxins. These results support the idea that permeation of both BoNT and L-TC through the intestinal cell layer depends on prior binding to sialic acid on the cell surface. This is the first report demonstrating that the binding of botulinum toxins to cell surface sialic acid leads to their transcytosis through intestinal epithelial cells.

A protease was purified from the culture medium of Clostridium botulinum serotype C strain Stockholm (C-St). The purified protease belonged to the cysteine protease family based on assays for enzyme inhibitors, activators and kinetic parameters. The protease formed a binary complex consisting of 41- and 17-kDa proteins held together non-covalently. The DNA sequence encoding the protease gene was shown to be a single open reading frame of 1593 nucleotides, predicting 530 amino acid residues including a signal peptide. The N-terminal region of the native enzyme underwent further proteolytic modification after processing by a signal peptidase. The protease introduced intermolecular cleavage into an intact single chain botulinum neurotoxin (BoNT) at a specific site. Homology modeling and docking simulation of C-St BoNT and C-St protease demonstrated that the specific nicking-site of the BoNT appears to fit into the deep pocket in the active site of the protease.

Botulinum neurotoxin (BoNT) is produced as a large toxin complex (L-TC) associated with nontoxic nonhemagglutinin (NTNHA) and three hemagglutinin subcomponents (HA-70,-33 and -17). The binding properties of BoNT to neurons and L-TC to intestinal epithelial cells are well documented, while those to other tissues are largely unknown. Here, to obtain novel insights into the pathogenesis of foodborne botulism, we examine whether botulinum toxins bind to vascular endothelial cells. BoNT and 750 kDa L-TC (a complex of BoNT, NTNHA and HAs) of Clostridium botulinum serotype D were incubated with bovine aortic endothelial cells (BAECs), and binding to the cells was assessed using sodium dodecyl sulfate polyacrylamide gel electrophoresis and Western blot. Both BoNT and L-TC bound to BAECs, with L-TC showing stronger binding. Binding of BoNT and L-TC to BAECs was significantly inhibited by N-acetyl neuraminic acid in the cell culture medium or by treatment of the cells with neuraminidase. However, galactose, lactose or N-acetyl galactosamine did not significantly inhibit toxin binding to the cells. This is the first report demonstrating that BoNT and L-TC bind to BAECs via sialic acid, and this mechanism may be important in the trafficking pathway of BoNT in foodborne botulism.

Cholesterol and bile acid leves were examined in young (8 weeks), middle-aged (12 months) and old (24 months) germ-free male rats, and young (8 weeks) and middle-aged (12 months) conventional male rats. The plasma cholesterol levels were higher in the aged rats, being more marked in the conventional rats. The liver cholesterol levels also increased with age and the increases were almost identical for both groups. No age-related changes were found in the biliary bile acid secretion, the pool size and distribution of bile acids in the bile, small intestine and large intestine, nor in the turnover frequency of bile acids, but the pool size in the young and middle-aged germ-free rats was much larger than that in the conventional rats. The turnover frequency was less in the germ-free rats. The bile acid synthesis presumed from the fecal bile acid excretion decreased in the aged germ-free rats but not in the conventional rats. A most remarkable age-related change was found in the bile acid composition; cholic acid increased and beta-muricholic acid derived from chenodeoxycholic acid in the rat decreased by aging, resulting in an increase of the CA/CDCA ratio (bile acids belonging to the cholic acid group/bile acids to the chenodeoxycholic acid group) in the bile, feces and pool. These results suggest that cholic acid synthesis increases while chenodeoxycholic acid synthesis is impaired by aging in rats.

"Takotsubo" cardiomyopathy is characterized by transient left ventricular dysfunction. We have reported a case of "Takotsubo" cardiomyopathy unrecognized during anesthesia because of no ischemic changes in monitored electrocardiogram (ECG). The patient was an 80-year-old woman undergoing open reduction surgery for fractures of the left tibia and ulna. Anesthesia was maintained with O2, N2O, sevoflurane and fentanyl. Sinus tachycardia was noted throughout anesthesia which was unresponsive to fluid loading and blood transfusion. ECG of limb leads showed no ST-T changes or abnormal Q waves and the blood pressure was stable during anesthesia. Postoperative echocardiography showed extensively decreased left ventricular wall motion with akinesis of the anterior wall and anterior septum from the mid-papillary level to apex. ECG showed negative T waves in V2-V6 without abnormal Q waves or ST changes. The increase in CPK-MB was very little. The abnormal left ventricular wall motion was completely recovered on the third postoperative day. Her perioperative cardiac event was diagnosed as "Takotsubo" cardiomyopathy by reversible ampulla-shaped ventricular dysfunction. She had no symptoms throughout the perioperative period and recovered without any sequela.

We gave propofol anesthesia to a patient with limb-girdle type of progressive muscular dystrophy. A 42 year-old male was to have skin graft for third degree burn. His respiratory function test showed %VC of 73.6% and %FEV1.0 of 107.6%. Arterial blood gas data were within normal ranges. He was anesthetized with propofol, fentanyl, vecuronium and nitrous oxide. During position change, Wenckebach type of second degree AV block occurred. AV block returned to sinus rhythm easily by injection of ephedrine hydrochloride and atropine sulfate, and reduction of propofol infusion rate. There were no perioperative respiratory complications and no clinical manifestations of malignant hyperthermia. Propofol anesthesia is suitable for limb-girdle type of progressive muscular dystrophy, because of very little possibility of triggering malignant hyperthermia, rapid awaking, minimal residual effects of the respiratory system, and easiness in controlling anesthetic depth.

We purified a novel serine proteinase inhibitor (serpin)-like protein from the bovine brain and named it B-43 from its molecular mass, 43 kDa. A cleaved peptide from B-43 was copurified with the native B-43. Partial amino acid sequencing of the purified B-43 showed that this protein was homologous to glia-derived nexin/protease nexin-1 (GDN/PN-1), plasminogen activator inhibitor 2, leukocyte elastase inhibitor (LEI) and placental thrombin inhibitor (PTI) among the serpins. Although B-43 had a similar amino acid composition to these serpins, the biochemical features of B-43 were different from them. B-43 did not form sodium dodecyl sulfate (SDS)-resistant serpin-proteinase complexes with thrombin, urokinase, pancreatic elastase and plasmin, suggesting that these proteinases were not the targets of B-43. In contrast to GDN/PN-1, B-43 did not have an affinity for heparin. B-43, having different biochemical properties from GDN/PN-1, appears to be an additional serpin expressed in the brain.

The effects of cholesterol feeding on serum and liver cholesterol levels, fecal and biliary bile acid levels, bile acid pool size and bile acid composition were examined in 2-, 12- and 24-month-old male germ-free rats. The major bile acids in these animals were cholic and beta-muricholic acids. Cholesterol feeding increased synthesis of bile acids by 3- to 4-fold, especially that of chenodeoxycholic acid (mainly beta-muricholic acid in the rat), decreasing the cholic acid/chenodeoxycholic acid (CA/CDCA) ratio in all rats regardless of age, even though the CA/CDCA ratio increased as a linear function of age in both diet groups. Cholesterol feeding increased the serum cholesterol level markedly in aged rats. This hypercholesterolemia may be produced by the increase in CA/CDCA ratio in aged rats.