We report two cases of paraganglioma originating in the paraseller region (case 1) and in the urinary bladder (case 2). The subject in case 1 was a 59-year-old man who was admitted into the hospital with dizziness, muscular weakness of the left extremities and cold sweating. Magnetic resonance imaging (MRI) revealed a tumor in the parasellar region. The subject in case 2 was a 39-year-old man who was hospitalized because he had a sense of residual urine. Computed tomography and MRI showed a mass of tumor tissue in the posterior region of the left ureteric orifice of the bladder. Imprint cytology of both tumors showed isolated, loosely attached sheet-like cells with abundant cytoplasm and round or oval nuclei. Histologically, both tumors consisted of round or polygonal cells in small packets separated by vascular fibrous septa. Immunohistochemically, both tumor cells were positive for NSE, S-100 protein, chromogranin A, and synaptophysin. Electron microscopic examination revealed neurosectretory granules in the cytoplasm of tumor cells in either of these two cases.

This is a report on a case of delirium due to a small amount of ketamine with voriconazole. A 58 year old male was treated for multiple myeloma and hip pain due to an extramedullary tumor following the administration of oxycodone, and voriconazole was administrated for his suspected mycotic pneumonia. His pain was refractory, so we started the administration of a small dose of ketamine (4 mg/hr) for analgesia, added to oxycodone. About 30 hours later, the delirium appeared but he complained of worsening hip pain, so we added 2 mg of ketamine rapidly. Immediately after the additional administration of ketamine, his delirium became more serious. We think the reason why a small amount of ketamine induced delirium is an interaction of ketamine and voriconazole. Ketamine is metabolized to norketamine, which is thought to be more harmless than ketamine, by cytochrome P 450 (CYP) (a part of by CYP3A4) and voriconazole is an inhibitor of CYP3A4. In cases of patients treated with voriconazole, ketamine should be more carefully administrated.