Over the last 20 years, 15 patients with myasthenia gravis and invasive thymoma have been treated in our department. Eight of these patients underwent either nontotal excision or were not operated on due to massive invasion, while 7 underwent total excision. These 15 cases represent 6.2% of the 242 myasthenic patients treated during this period. Six of the 8 nontotal excision cases died, and 2 of the 7 total excision cases succumbed. The prognosis of total excision cases was better than that of nontotal excision cases. The overall 5-year survival rate was 73%, and the 10-year survival rate 20%. Total excision of the thymoma, if possible, and high doses of corticosteroids and combination chemotherapy for the remaining tumor seem to be the treatments of choice.

A 37-year-old male, a poorly-controlled insulin-dependent diabetic patient, was admitted to our hospital with complaints of high fever and confusion. Laboratory data showed hyper glycemia, positive inflammatory reaction and liver dysfunction. Blood culture demonstrated Yersinia enterocolitica. Liver CT scan showed multiple low density areas. These data were consistent with a diagnosis of liver abscess secondary to Yersinia enterocolitica. He died of disseminated intravascular coagulation; subsequent autopsy confirmed the clinical diagnosis. Liver abscess secondary to Yersinia enterocolitica with septicemia is rare, but has been reported in compromised hosts. In the mechanism of this disease, the alimentary tract has been suggested to be the port of entry in most cases. (Internal Medicine 31: 1125-1127, 1992 Key words: sepsis, diabetes mellitus, serotype 03 antibody, hepatic encephalopathy Intr oductionWe treated a case of sepsis and multiple liver ab scesses due to Yersinia enterocolitica (Y.E) in an insulin dependent diabetes mellitus patient. In Japan, it is rare to find severe infection caused by Y.E., especially in adult patients. Case ReportA 37-year-old diabetic man was treated with insulin for ten years, but his diabetic condition was not well controlled. On September 27, 1986, he began to suffer from high fever and diarrhea; nausea, vomiting and mild disturbance of consciousness later developed, and he was admitted to our hospital on November 7, 1986. On admission, BP was 94/70 mmHg, body temperature was 37.4°C, and consciousness was confused. The patient's skin was dry; there were no other abnormal findings on physical examination.Laboratory data showed WBC 5800/mm3 (Band 3, Seg (Fig. 1) showed multiple round low density areas (2-5cm in diameter) in the bilateral lobes of the liver. Ultrasound also showed multiple clear margins around hypoechoic lesions. These data suggested liver abscesses secondary to Y.E. with septicemia. Chemo therapy was started with ceftizoxime (CZX) 6g/day; piperacillin (PIPC) 4 g/day was later added. Neurological signs (flapping tremor, confusion and dyscalculia) were thought to be caused by hepatic encephalopathy. Lactulose and aminoleban were administrated, and the patient's serum ammonia level decreased, but the disturbance of consciousness did not show any improvement. Spike fever continued and serum albumin decreased to 0.9 g/dl.Generalized edema, pulmonary effusion, ascites and jaundice developed. Diuretics and frozen fresh plasma were administered, but hypoalbuminemia, generalized edema, and pulmonary effusion failed to improve. On the 17th day after admission, gastrointestinal bleeding occured. He died of disseminated intravascular coagu lation (DIC) and pulmonary edema on the 29th day after admission.

It is widely accepted that a long-term, alternate-day administration of adrenal corticosteroids after thymectomy is one of the most effective treatments of myasthenia gravis. However, some patients with myasthenia gravis show a tendency to develop steroid dependency, and require extremely prolonged administration of fairly high doses of steroids. Various types of adverse reactions to steroids are likely to occur in such cases. To avoid this, intermittent, single-dose administration of steroids was performed on a trial basis in the present study. Prednisolone, in doses of 50-100 mg, was given once every 3-7 days in three steroid-dependent myasthenic patients, in one case for up to 6 years. The effects of the intermittent treatment were as good as, and adverse effects less frequently found than in single-dose, alternate-day administration.

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