We report a 65-year-old woman with isolated adrenocorticotropic hormone (ACTH) deficiency. The patient was transported to the emergency outpatient department by ambulance complaining of malaise and nausea. Because her laboratory data revealed hyponatremia, we performed endocrinological examinations and diagnosed isolated ACTH deficiency. After admission, she went into a delirious state and suffered from takotsubo cardiomyopathy due to adrenal insufficiency. Replacement therapy with hydrocortisone sufficiently improved her delirium and cardiomyopathy. We conclude that her unstable mental state and myocardial dysfunction were closely related to adrenal insufficiency and suggest that adrenal crisis may cause delirium and Takotsubo cardiomyopathy.
Unilateral small kidney with ureteral obstruction was discovered in a 74-year-old female cadaver during an anatomical dissection course. In order to elucidate the histogenesis of renal dysplasia, we carried out histochemical and immunohistochemical analyses. On macroscopic view, the kidney was approximately 3 cm in length, 2 cm in width and weighed only 9 g. Although the ureter ran from the renal hilus to the bladder, its width was under 2 mm. The renal parenchyma was extremely thin and there was a large congested vein in the renal sinus. On microscopic examination of the kidney, we observed that numerous developing renal tubules had cytokeratin-positive epithelia, most of which were surrounded by concentric fibrosis. However, we could not detect any structures resembling the collecting duct, renal tubules, renal pelvis, or glomeruli. The concentric mesencymal fibrous tissue surrounding the immature renal tubules contained the smooth muscles that were positive for h-caldesmon. Serial sections of the ureter revealed several small and discontinuous lacunae lined by cuboidal and transitional epithelium, which did not constitute a patent lumen through the bladder. This case is a rare case of renal dysplasia with defect in recanalization of the ureteral bud during the early developmental stage.
SummaryA 43-year-old man was admitted to our hospital with ST-segment elevation acute coronary syndrome. He had experienced myocardial infarction 19 months previously, and a bare-metal stent (BMS) had been implanted in the culprit distal right coronary artery at another hospital. Emergency coronary angiography showed thrombotic in-stent occlusion of the BMS. Intravascular ultrasound revealed an undersized stent compared with the size of the vessel and late stent malapposition (LSM) with abundant thrombi. The lesion was successfully recanalized via thrombectomy and plain old balloon angioplasty. Optical frequency domain imaging performed at follow-up coronary angiography confirmed the improvement of the LSM and incomplete neointimal stent coverage. This report illustrates the importance of imaging modalities in elucidating the mechanism of BMS-related very late stent thrombosis.(Int Heart J 2018; 59: 209-212) Key words: Acute coronary syndrome, Incomplete neointimal stent coverage, Late stent malapposition A lthough very late stent thrombosis (VLST) following bare-metal stent (BMS) implantation is a rare phenomenon, it causes severe complications once it occurs. Neoatherosclerosis plays an important role in BMS-related VLST, especially in elective cases. 1,2) However, in cases of acute coronary syndrome, late stent malapposition (LSM) is the primary mechanism behind BMS-related VLST, as confirmed by intravascular ultrasound (IVUS) imaging.3) In clinical settings, however, detailed image analysis using optical frequency domain imaging (OFDI) has rarely been reported. In the present case, IVUS and OFDI images of BMS-related VLST revealed an undersized stent with LSM and possibly incomplete neointimal stent coverage, even after 19 months following the initial BMS implantation for acute coronary syndrome. Case ReportA 43-year-old man was admitted to our hospital with sudden chest pain. The patient had coronary risk factors including dyslipidemia and current smoking. He had experienced myocardial infarction 19 months previously and undergone percutaneous coronary intervention (PCI) in the distal right coronary artery (RCA) with a BMS (Multi-link Vision 2.5/23 mm, Abbot Vascular, Santa Clara, USA) at another hospital. At the same time, an additional BMS (Multi-link Vision 3.5/23 mm, Abbot Vascular) was implanted for 75% stenosis in the mid-RCA. Final IVUS confirmed optimal stent expansion to the normal size with well-apposed stent struts in both stents. He was discharged on dual antiplatelet therapy (acetylsalicylic acid 100 mg and clopidogrel 75 mg once daily). The clopidogrel was discontinued 12 months after the initial PCI.On admission, electrocardiography showed STsegment elevation in the inferior leads. Emergency coronary angiography revealed total thrombotic in-stent occlusion at the distal RCA (Figure 1). A 6-Fr guiding catheter (Mach-1 FR 3.5, Boston Scientific, Natick, MA, USA) was engaged into the RCA, and thrombectomy was performed with an aspiration catheter (Thrombuster SLIII , Kaneka, Osaka, Japan). After...
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