Health effects from exposure to organophosphate pesticides in workers and residents in Israel

Major findings from our work on exposures and effects from organophosphate-containing pesticides in selected occupational and community patients and groups in Israel are reviewed as a basis for recommending control measures. The worker groups were pilots, ground-crews, and field workers; exposed nonworkers were adults and children living in kibbutzim with drift exposures, and household residents in houses treated by pest exterminators. In all groups, evidence of exposure-illness associations was found even though persons with acute poisoning were not seen. Complaints (headache, dizziness, fatigue, nausea, breathing problems, abdominal cramps, and tingling in extremities) were associated with within-normal depressions in cholinesterase activity. Whole blood and plasma cholinesterase activity were slightly more sensitive indicators of mixed exposure than red blood cell cholinesterase activity. High alkyl phosphate levels and symptoms were seen in individuals with within-normal limit depressions in cholinesterase activity. Complaints of weakness and tingling in hands and feet, together with low-grade changes in nerve conduction, suggest the possible influence of agents with a neurotoxic esterase-type activity independent of cholinesterase activity. Transient in-season neuropsychological changes in tests of mood status and performance were associated with exposure. Recommendations for exposure reduction include: accelerating the already declining use of pesticides in general, and organophosphates in particular; promoting the shift from more to less toxic organophosphates and other pesticides; and introducing rigid performance specifications for closed systems in loading and mixing at end-user sites. Dermal protection remains a problem. Cholinesterase activity levels and symptom interviews are useful for monitoring workers at risk, but alkyl phosphate levels are the definitive measure of exposure, surveys, investigations and surveillance.

The role of autologous blood stem cells in support of high-dose therapy for multiple myeloma

During the last few years, high-dose therapy with hemopoietic stem cell support has become a well-admitted therapeutic option for young patients with MM. The role of allogeneic or autologous graft and of blood rather than bone marrow as the source of hemopoietic stem cells must be further investigated. Autologous PBSC transplantation has, however, both practical and theoretic advantages over allogeneic and autologous BMT: (1) It can be applied to most patients, especially if blood stem cells are collected early in the course of therapy. (2) It usually induces relatively rapid hematologic reconstitution. (3) In comparison with autologous BMT, it appears to minimize the hazard of the reinfusion of malignant cells.

A nonsense mutation in the LDL receptor gene leads to familial hypercholesterolemia in the Druze sect

Familial hypercholesterolemia (FH) is an autosomal dominant disease caused by mutations in the LDL receptor gene. Here we characterize an LDL receptor mutation that is associated with a distinct haplotype and causes FH in the Druze, a small Middle Eastern Islamic sect with a high degree of inbreeding. The mutation was found in FH families from two distinct Druze villages from the Golan Heights (northern Israel). It was not found neither in another Druze FH family residing in a different geographical area nor in eight Arab and four Jewish FH heterozygote index cases whose hypercholesterolemia cosegregates with an identical LDL receptor gene haplotype. The mutation, a single-base substitution, results in a termination codon in exon 4 of the LDL receptor gene that encodes for the fourth repeat of the binding domain of the mature receptor. It can be diagnosed by allele-specific oligonucleotide hybridization of PCR-amplified DNA from FH patients.

Interleukin-6 antisense oligonucleotides inhibit the growth of human myeloma cell lines

IL-6 has been shown to be a plasmacytoma growth factor in mice and is believed to play a key role in the development of human multiple myeloma. We investigated the IL-6 requirements for the growth of two human myeloma cell lines, U 266 and RPMI 8226. These cell lines secreted minute amounts of IL-6 (20 U/ml) and featured IL-6 mRNA. IL-6 receptors were detectable at the surface of malignant cells by immunofluorescence. Antibodies to IL-6 did not alter the proliferation of these myeloma cells. There was a dose-dependent decrease, however, in [3H]-thymidine uptake in the presence of IL-6 antisense (and not sense) oligodeoxynucleotides; in the presence of 20 microM IL-6 antisense, an 80 and 95% inhibition of the proliferation of U 266 and RPMI 8226 cells was observed, respectively. These results provide strong evidence for an IL-6 autocrine proliferation of myeloma cells which may occur via internal interaction between IL-6 and the IL-6 receptor.

Effect of urine and urine components on the chemiluminescent response of bacteria-stimulated polymorphonuclear leukocytes

The role of polymorphonuclear leukocytes (PMN) found in urine during infectious episodes is still unknown. Opsonophagocytosis of Escherichia coli by normal blood PMN in the presence of urine was measured using a chemiluminescence (CL) assay. PMN were challenged by a type I fimbriated E. coli strain shown to elicit a CL response through attachment to the mannose-containing receptors on the leukocytes. In the presence of urine the CL response decreased significantly. Urine osmolality due to inorganic salts partially caused this decrease. A higher inhibitory effect was elicited by urea. Under otherwise similar conditions, the presence of an additional CL-inhibiting factor, most probably a protein, was detected in urine; however, its identity has not yet been defined. In vitro and in vivo urine dilution improved PMN function. No difference in effect on CL response was found between urine obtained from 25 children with recurrent urinary tract infections and urine from 15 age-matched controls.

Phenotype and immunoglobulin gene configuration of blood B cells from patients with multiple myeloma

We have studied the phenotype and the immunoglobulin gene configuration of blood B cells from 15 patients with stage III multiple myeloma (MM) at diagnosis. Highly purified B cells (greater than 90% CD20 positive cells) were obtained after L-leucine methyl ester monocyte depletion and elimination of T cells by rosetting. The percentage of B cells with surface immunoglobulin (sIg) featuring the same light and heavy chain isotype as the serum monoclonal immunoglobulin was very low, except in one patient, in whom 25-30% of B cells displayed surface and cytoplasmic immunoglobulin (cIg) sharing idiotypic determinants with the serum monoclonal IgG kappa. In all cases but one the percentage of circulating plasma cells accounted for less than 2% of the enriched B cell preparations. In one patient purified B cell population contained 30% of plasma cells and the immunoglobulin gene study revealed a rearranged JH hybridizing fragment identical in bone marrow and blood B cell DNA samples. In the other 14 cases no rearranged fragment was detected although we used a technique allowing the detection of at least 2% clonal cells. The absence of clonal cells in the patient whose B cells contained a high percentage of cells featuring surface IgG molecules was confirmed on purified sIgG-positive cells. In addition CD20-positive cells from this patient did not contain gamma mRNA. Therefore the IgG molecules were clearly extrinsic. Although the existence of clonal B lymphocytes or of myeloma idiotype related B cells cannot be ruled out, they escape detection by sensitive genetic studies of immunoglobulin genes.

The pupillary effects of retrobulbar injection of botulinum toxin A (oculinum) in albino rats

Botulinum toxin (BoTx) has been clinically used in the treatment of localized dystonic states such as blepharospasm, as well as in strabismus. Reported side effects have included primary excessive weakness of neighboring extraocular muscles. To evaluate possible involvement of the iris, we injected BoTx into the retrobular space of albino rats. Ipsilateral mydriasis with cholinomimetic supersensitivity developed in the treated animals. There was no apparent optic nerve dysfunction. The authors observed these effects using BoTx doses insufficient to cause clinical weakness or electrophysiological evidence of generalized neuromuscular dysfunction. The mydriasis disappeared spontaneously within 2-3 weeks. Higher BoTx doses resulted in severe neuromuscular paralysis and death. These findings were consistent with clinical botulism, which may include autonomic paralysis. The site of BoTx action could be the ciliary ganglion or cholinergic terminals in the iris. The authors concluded that side effects of BoTx were not necessarily limited to striated muscle weakness.

Specific proliferative responses following the induction of experimental SLE in mice

We have previously reported the induction of experimental systematic lupus erythematosus (SLE) in mice by immunization with a human monoclonal antibody that expresses a common anti-DNA idiotype (16/6 Id). Following immunization, antibodies directed against various nuclear autoantigens could be detected in the sera of the mice. In the present study, we investigated the proliferative responses of lymph node cells to one particular autoantigen (DNA) following the induction of experimental SLE. Cells reactive with ssDNA could be detected following immunization of BALB/c mice with the 16/6 Id. The appearance of these DNA-reactive cells succeeded the appearance of 16/6 Id-specific cells. The activation of this subset of autoreactive cells could be achieved only by the immunization of the mice with the 16/6 Id, but not by their immunization with DNA, thus suggesting that the induction of experimental SLE is associated with the alteration of the low responsive potential of the mice to DNA.

Differential effects of low and high concentrations of interleukin 6 on human B cells

In this report we have studied the functional effects of a wide range of interleukin 6 concentrations on human B cells. B cells purified from tonsils and from five of six spleens proliferated directly in a dose-dependent manner in the presence of low concentrations (1-100 pg/ml) of IL 6 whereas B cells from the sixth spleen proliferated only after in vitro anti-mu antibodies activation. Only large B cells (presumably in vivo activated B cells) were responsive to IL 6. High concentrations of IL 6 (1-10 ng/ml) did not trigger B cell proliferation but were able to up-regulate the expression of the B5 activation antigen on B cells, whereas the expression of two other B cell antigens (CD20 and CD23) was unchanged. At all concentrations of IL 6 tested (0.01-10 ng/ml) no B cell differentiation occurred after 7 days culture. Depletion before culture of B5+ cells from the B cell-enriched spleen cell preparation abolished both the proliferative effect and up-regulation of B5 antigen induced by IL 6, indicating that this lymphokine acted primarily on activated B cells. This differential effect of "low" and "high" concentrations of IL 6 on activated B cells may solve controversy on the role of IL 6 as an early or late agent in B cell maturation.

Neurosarcoidosis: signs, course and treatment in 35 confirmed cases

Thirty-five cases of biopsy-proven sarcoidosis with neurologic manifestations are reported. Neurosarcoidosis was the presenting symptom in 31% of cases and the only clinical manifestation in 17%. Mean follow-up time was 48 months. Central nervous system involvement was observed in 37% and meningitis in 40% of patients. Other manifestations were cranial nerve palsies (37%), peripheral neuropathy (40%), and myopathy (26%). Multiple neurologic manifestations were present in 51% of cases. All but 4 were treated with corticosteroids. Another immunosuppressive agent or cerebral irradiation was added in 6 and 2 patients, respectively. Complete recovery was observed in 46%, improvement in 46%, 4% remained stable, and 4% worsened. There were no deaths. We advocate treating neurosarcoidosis with corticosteroids as early as possible. If the patient's condition worsens, additional immunosuppressive agents or cerebral irradiation is warranted.

Prevalence of hereditary properdin, C7 and C8 deficiencies in patients with meningococcal infections

High incidence of hereditary complement (C) deficiencies was found among 101 patients who had a meningococcal disease. This study revealed 11 non-related patients with complete C deficiency: five deficient in C7, three in C8, two in properdin and one in C2. Additional C-deficient individuals, most of them with no history of severe bacterial infections, were detected in family studies. The C8-deficient patients were found to have a selective deficiency of the C8-beta subunit and a reduced expression of the alpha/gamma subunit. Only a few families with properdin deficiency have been described so far. However, it is likely that frequent analysis of the activity of the alternative C pathway in survivors of severe bacterial infections will disclose numerous properdin-deficient patients. All our C7-, C8- and properdin-deficient patients are Sephardic Jews whose families originated from Morocco, Yemen (C7 and C8 deficient) or Tunisia (properdin deficient). This and other findings indicate that the type of complement abnormality found in association with meningococcal infections varies with the ethnic origin of the patient.

Riboflavin deficiency and the function and fluidity of rat erythrocyte membranes

The effect of riboflavin deficiency on the fluidity and function of the red blood cell (RBC) membrane and on the activity of some enzymes involved in antioxidant defense mechanisms was studied. Growing male rats were fed an experimental (riboflavin-deficient) or a control (riboflavin-supplemented) diet. Following 7 wk of feeding, RBC from riboflavin-deficient rats contained higher levels of peroxidation products, most likely due to decreased glutathione reductase activity. An elevation in glutathione peroxidase activity was also observed whereas the activity of catalase and superoxide dismutase was not affected. Membrane fluidity was studied by fluorescence polarization, using 1,6-diphenyl-1,3,5 hexatriene (DPH) as a probe. The fluidity of RBC membranes isolated from riboflavin-deficient rats was significantly lower than that of the controls. This decreased fluidity was accompanied by an increase in the activity of the membrane-bound enzyme acetylcholinesterase. This study demonstrated that a decrease in cells' ability to cope with peroxidative damage as a result of riboflavin deficiency may lead to changes in the fluidity and function of membranes.

Hypodipsic hypernatremia and hypertriglyceridemia associated with cleft lip and cleft palate: a new hypothalamic dysfunction syndrome?

We report on a 4-month-old girl with congenital hypodipsic hypernatremia resulting from decreased sensitivity of the hypothalamic osmoreceptors with increased tonicity in association with hyperlipemia and cleft lip and cleft palate. We postulate that the link among these various derangements is hypothalamic dysfunction.

Interleukin 6 dependence of spontaneous in vitro differentiation of B cells from patients with IgM gammapathy

Blood B cells from eight patients with clonal lymphoid disorders characterized by monoclonal IgM secretion (four with malignant plasmacytic proliferation typical of Waldenström macroglobulinemia and four without overt lymphoid neoplasia) were found to spontaneously differentiate in vitro into plasma cells. In all instances, monoclonal plasma cells (8-45% of the cells) were generated from extensively purified B cells or T-cell-depleted peripheral blood mononuclear cells after a 7-day culture period, with a corresponding high rate of IgM secretion into the culture medium. This differentiation occurred in the absence of any cell proliferation process as measured by [3H]thymidine uptake at day 2 or 4. Normal B cells did not differentiate under the same experimental conditions. Detection of interleukin 6 (IL-6) bioactivity in all patients' B-cell culture supernatants as well as of IL-6 mRNA in freshly prepared, uncultured B cells in the two cases studied by in situ hybridization suggested that IL-6 secretion by B cells may play a role in this process. Moreover, in the four patients without overt lymphoid proliferation, B-cell differentiation was significantly inhibited (60-80%) in the presence of anti-IL-6 antibodies. In contrast, anti-IL-6 antibodies did not preclude the differentiation into plasma cells of B cells from the four patients with bona fide Waldenström macroglobulinemia. These results suggest a two-step pathogenesis for such human lymphoplasmacytic clonal proliferations, the initial stage being characterized by an IL-6-dependent autocrine differentiation pathway.

Intralipid infusion in patients with familial hypercholesterolemia. Effect of serum and plasma lipoproteins on platelet aggregation and on macrophage cholesterol metabolism

Intralipid infusion into normal volunteers was recently shown to possess anti-atherogenic properties. We studied the effect of intralipid infusion in patients with severe Familial Hypercholesterolemia (FH) refractory to conventional therapy. FH patients and normal subjects, who served as controls, were given an intravenous infusion of intralipid for 6 h. Serum samples taken from both groups before, during and after intralipid infusion were studied for their ability to inhibit cellular cholesterol accumulation by macrophages. A significantly lower rate of cellular cholesterol esterification (of 46%, P less than 0.005 and 44%, P less than 0.005 in patients and normals, respectively) was demonstrated in macrophages incubated with serum obtained during intralipid infusion compared to those incubated with preinfusion serum. The maximal effect was demonstrated with serum samples taken at the end of the infusion, but the inhibitory effect persisted even at 24 h post-infusion. It was found that chylomicron like particles could induce the above-mentioned effects on macrophage cholesterol esterification. A significant decrement of 50% (P less than 0.005) in aggregation of platelets isolated from plasma samples taken during and after intralipid infusion from both groups was demonstrated, when compared to platelets isolated in the preinfusion state. This effect persisted 18 h subsequent to infusion. We conclude that intralipid infusion abolishes serum ability to stimulate cholesterol esterification in cultured macrophages, and exhibits inhibitory effects upon platelet aggregation. If similar events occur in the arterial wall, intralipid might inhibit foam cell formation.

[Intralipid infusion in familial hypercholesterolemia]

Intralipid, used for intravenous alimentation and containing triglyceride emulsion particles and phospholipid liposomes, has been shown to induce regression of atherosclerosis in experimental animals. Intravenous infusions of Intralipid were given to 2 patients with severe familial hypercholesterolemia refractory to conventional therapy, and to control subjects. Intracellular cholesterol esterification was inhibited in macrophages incubated with serum taken during infusions as compared to the preinfusion state, with maximal effect after 6 h of infusion. A significant decrease in platelet aggregation was also demonstrated in both groups, which persisted for 18 h after infusion. We conclude that infusion of Intralipid may have anti-atherogenic effects and plan to use it in patients with severe atherosclerosis.

[Massive pericardial effusion following minoxidil]

Minoxidil is a potent antihypertensive which is reserved for severe cases. A 58-year-old man admitted for evaluation of progressive dyspnea and peripheral edema had been taking Minoxidil, Normiten and Lasix for severe hypertension. Echocardiography disclosed a massive pericardial effusion but there were no signs of tamponade. Discontinuation of Minoxidil resulted in complete clearance of the pericardial fluid within 3 months. Awareness of this potentially fatal side-effect of Minoxidil is mandatory.

Gastrointestinal abnormalities in the syndrome of mosaic trisomy 9

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Nutritional complications in an infant fed exclusively on homemade sesame seed emulsion

A 3-month-old infant was exclusively fed a high calorie homemade sesame seed emulsion for 4 weeks. As a result of the milk content, the infant developed hypermagnesemia, hypokalemia, hyponatremia, and hypovitaminosis C. Although the mixture was highly caloric and the infant's intake was good, he showed profound failure to thrive. Analysis of the emulsion indicated that this complication was primarily due to the heterogeneity of the emulsion's caloric content resulting from a settling process which occurred after the emulsion was placed in the infant's bottle. This settling resulted in the portion containing the most calories being the last to reach the infant's mouth. These findings indicate that whenever a vegetarian diet is provided to a bottle-fed infant, the potential heterogeneity of the mixture's caloric content, as well as the contents themselves, should be considered.

Recurrent ascites in an infant with perinatally acquired cytomegalovirus infection

We describe an infant with symptomatic perinatally-acquired cytomegalovirus (CMV) infection manifested by fever, anaemia, thrombocytopenia and hepatosplenomegaly. This infant developed recurrent episodes of severe ascites during which the virus was isolated from his urine. This rare hepatic manifestation of neonatal CMV infection has, to the best of our knowledge, only been reported twice in aborted fetuses with intrauterine systemic CMV infection.

Massive haematemesis--presenting symptoms of cystadenocarcinoma of the pancreas

A 43 year old woman presented with attacks of abdominal pain, haematemesis and hyperamylasaemia. Gastrointestinal X-rays and repeated upper gastrointestinal endoscopy failed to reveal the source of bleeding. Ultrasound and computed tomographic scan demonstrated a calcified mass in the tail of the pancreas. Surgical exploration revealed a solitary mass in the pancreas and histological examination showed cystadenocarcinoma. The patient died 2 years later because of local recurrence, but haematemesis and melaena did not recur. This case presents an unusual manifestation of cystadenocarcinoma of the pancreas with massive bleeding from the tumour via the pancreatic duct and associated pancreatitis. Other possible reasons for bleeding with cystadenocarcinoma of the pancreas are discussed.

Treatment of aggressive multiple myeloma by high-dose chemotherapy and total body irradiation followed by blood stem cells autologous graft

Eight patients with stage III aggressive multiple myeloma, refractory to current chemotherapy in six cases, were treated by high-dose chemotherapy (nitrosourea, etoposide, and melphalan) (HDC) and total body irradiation (TBI), followed by autografting with blood stem cells. These cells were previously collected by leukapheresis performed during hematologic recovery following cytotoxic drug-induced bone marrow aplasia. Seven patients were alive 9 to 17 months after HDC-TBI and graft. One died at day 40 from cerebral bleeding. All living patients achieved a 90% or greater reduction in tumor mass. In two cases, a complete remission (CR) has persisted at a follow-up of 15 and 16 months. Three patients have been well and off therapy with stable minimal residual disease (RD) since 10, 11, and 17 months, respectively. A patient in apparent CR and another with RD have relapsed 9 to 12 months posttreatment. Autologous blood-derived hematopoietic stem cells induced successful and sustained engraftment in all living patients. These results, although still preliminary, indicate that HDC and TBI, followed by blood stem cells autograft, which has both practical and theoretical interest over allogeneic or autologous bone marrow transplantation, deserve consideration in selected patients with multiple myeloma.

Release of D-[3H]aspartate and [14C]GABA in rat hippocampus slices: effects of fatty acid-free bovine serum albumin and Ca2+ withdrawal

Extended incubation of hippocampus slices in the presence of fatty acid-free bovine serum albumin (FAF-BSA) strongly enhanced the release of D-[3H]aspartate and [14C]GABA induced by veratridine. Saturation of the FAF-BSA with oleic acid abolished the enhancing effect. Spontaneous release and K+-induced release were not significantly changed by the addition of FAF-BSA. Amino-oxyacetic acid in the medium enhanced the veratridine-induced release of D-[3H] aspartate. The spontaneous release of [14C]GABA was greatly increased by Ca2+ withdrawal. With the further addition of EGTA the spontaneous release in the absence of Ca2+ increased more than 8-fold over the measured in the presence of 1.5 mM Ca2+. The enhanced release caused by Ca2+ withdrawal was totally blocked by tetrodotoxin. The toxin was effective even when added after the spontaneous release in the absence of Ca2+ was already proceeding at a high rate. The veratridine-induced release of [14C]GABA was also considerably augmented by Ca2+ withdrawal. D-[3H]aspartate release, studied simultaneously with [14C]GABA by double labeling, did not show enhanced spontaneous release upon Ca2+ withdrawal. The findings provide evidence that the enhanced [14C]GABA release caused by Ca2+ withdrawal is mediated by voltage-dependent Na+ channels.

Adenosine deaminase deficiency with late onset of recurrent infections: response to treatment with polyethylene glycol-modified adenosine deaminase

We report a 5-year-old girl with adenosine deaminase (ADA) deficiency who was asymptomatic during the first years of life. At 3 years of age, she developed chronic and recurrent sinopulmonary infections, and at 4 1/2 years of age she had one major infection with Streptococcus pneumoniae (bacteremia and septic arthritis of the hip). Immunologic evaluation at 5 years of age revealed persistent lymphopenia, decreased helper-suppressor T cell ratios, and low proliferative responses to mitogens. The IgG, IgM, and IgA levels were normal; the IgG2 level was low normal or below normal. The patient had specific antibodies against toxoids and viral antigens but failed to produce antibodies against Haemophilus influenzae type b and pneumococcal polysaccharides. Although no symptoms of allergy were present, she had persistent eosinophilia and elevated IgE levels. The patient had 0.6% of normal ADA activity in erythrocytes and approximately 1% of normal ADA activity in peripheral blood mononuclear cells. Beginning at 6 years of age, she was treated with weekly injections of polyethylene glycol-modified bovine ADA. This treatment was well tolerated and effectively reversed the biochemical consequence of ADA deficiency. Concomitantly, she improved clinically and her T lymphocyte numbers and blastogenic responses to mitogens in vitro became normal. The late onset of clinical symptoms and relatively benign clinical course in this patient emphasize the need to consider ADA deficiency in a broad spectrum of immunodeficient children.

Phosphate depletion syndrome: case report with bone and muscle histology findings and review of the literature

A 44-yr-old woman with a 16-yr history of heavy antacid ingestion was evaluated for severe weight loss, weakness, bone pain, and multiple fractures. Laboratory investigation revealed severe hypophosphatemia with undetectable phosphate in the urine. Serum parathyroid hormone (PTH), 25-hydroxyvitamin D, and 1,25-dihydroxyvitamin D levels were normal. Transiliac bone biopsy revealed evidence of mineralization defect compatible with hypophosphatemic osteomalacia. Bone densitometry documented decreased bone density with a low mineral content. Management included withdrawal of antacids and provision of phosphate-supplemented enteral nutrition, which resulted in prompt weight gain and resolution of the clinical and biochemical abnormalities. The pathogenesis, diagnosis and histological features of hypophosphatemic osteomalacia are discussed.

Cerebrospinal fluid findings in infants with nonpolio enteroviral meningitis

We studied 25 infants aged less than 9 months who were diagnosed as having nonpolio enteroviral meningitis (EM) confirmed by virus isolation from cerebrospinal fluid (CSF). CSF protein, glucose and cellular content in these infants was compared with that of 125 age-matched febrile infants without cerebromeningeal illness. In order to control for changes occurring in the CSF during the first 2 months of life, the studied infants and the control subjects were stratified into 2-week age-groups and were compared. All but three of the infants with EM had increased CSF leukocyte count, and 10 infants showed domination of the polymorphonuclear leukocytes in the CSF. Only two had increased CSF protein levels, and low CSF/blood glucose ratios were found in all but two cases. None of the infants with EM had increased values of CSF protein concomitant with decreased CSF/blood glucose ratio. CSF in EM is characterized by increased white blood cell count in contrast with normal or near-normal CSF protein and glucose levels. In some infants, enterovirus isolation may be the only evidence of EM.

A modified, solid phase radioimmunoassay for the differential diagnosis of acute and convalescent phases of hepatitis A infection

The commercial assays for diagnosing the presence of hepatitis A antibodies (HAVAB; Abbott Laboratories, North Chicago, IL) or the presence of IgM class anti-hepatitis A virus antibodies (HAVAB-M; Abbott) do not provide precise information as to the timing of the acute infection. IgM class antibodies are detected as late as six months after the acute infection. In this study the authors describe a modified HAVAB test that inactivates the IgM class antibodies. It thus measures the proportion of IgG antibodies out of the total anti-hepatitis A virus antibodies. In a study of 139 patients with impaired liver function, the available and modified tests showed good agreement except for the convalescent phase of hepatitis A. During serial testing for three months after the acute infection, the commercial tests continuously detected IgM class antibodies. The modified test detected predominantly IgG class antibodies from four weeks on. By six weeks, 85% of the patients had predominantly IgG class antibodies. The modified test thus provides information on the timing of recent hepatitis A infection.

Serum lipoproteins in home total parenteral nutrition patients

Patients maintained in our home total parenteral nutrition (HTPN) program receive very small amounts of cholesterol in their solutions. Because of the severe intestinal insufficiency which is characteristic of this group, they do not absorb significant amounts of cholesterol or bile salts from their intestines. We investigated the serum lipoproteins in nine patients maintained on HTPN for 36 +/- 4 (mean +/- SEM) months. Fat emulsions were given twice a week as a source of essential fatty acids. Mean serum cholesterol 110 +/- 6.5 mg/dl, LDL-cholesterol 75 +/- 6 mg/dl, and HDL-cholesterol 29 +/- 1 mg/dl, were at or below the 5th percentile compared with age- and sex-matched Lipid Research Clinic controls. HDL-cholesterol to serum cholesterol ratio was in the normal range (0.25 +/- 0.30). The mean serum cholesterol did not rise, but the mean serum triglyceride rose significantly from 72 +/- 4 to 104 +/- 16 mg/dl (p less than 0.05) immediately after completion of TPN infusions with fat emulsions. There was a negative correlation between the length of HTPN therapy and the total serum cholesterol (r = 0.43, p less than 0.05). Thus, HTPN patients have markedly depressed concentrations of total serum cholesterol, LDL-cholesterol, and HDL-cholesterol, but the ratio of HDL cholesterol to total serum cholesterol is in the normal range.

Postaxial polydactyly in association with neurofibromatosis

Von Recklinghausen neurofibromatosis may present many skeletal abnormalities as common features. We describe a family with postaxial polydactyly and neurofibromatosis, an association which has not been previously reported. The special characteristics of postaxial polydactyly of this family were its bilateral and symmetrical appearance, its limitation only to males, simultaneous presence of types A and B in the same patient, and its occurrence in both hands and feet. Postaxial polydactyly type A appeared only in the affected neurofibromatotic members of this family.

Hyperkalemia as a late side effect of prolonged adrenocorticotropic hormone therapy for infantile spasms

Two infants developed hyperkalemia shortly after cessation of prolonged ACTH therapy for infantile spasms. We wish to call for cautious approach at time of cessation of prolonged ACTH therapy because of possible unexpected and only partially understood hazardous side effects such as hyperkalemia.

Sudden deafness in a patient with temporal arteritis

A patient with anemia and elevated erythrocyte sedimentation rate presented with sudden hearing loss. The diagnosis of temporal arteritis was verified by temporal biopsy. Initiation of corticosteroid therapy reversed the disease manifestations and within a short period improved the patient's hearing.

D-[3H]aspartate release from hippocampus slices studied in a multiwell system: controlling factors and postnatal development of release

Medium components and various factors were tested to define optimal conditions for D-[3H]aspartate release. Isolation of the hippocampus and preparation of the slices in a medium without Ca2+ increased the release of D-[3H]aspartate in response to veratridine when subsequently tested in a regular Ca2+ containing medium. Apparently, the absence of Ca2+ during preparation of the slices reduced irreversible damage due to hypoxic conditions which prevail throughout the interval between killing the animal and immersion of the slices in a well oxygenated medium. Substitution of 10 mM Mg2+ for Ca2+ was an efficient procedure to test for Ca2+ dependence of D-[3H]aspartate release induced by veratridine. The inhibition was readily reversible when Ca2+ was readded. Veratridine (50 microM) was superior to high K+ (45 mM) in inducing D-[3H]aspartate release under all conditions tested in slices of mature animals. Furthermore, veratridine-induced release could be completely blocked by tetrodotoxin while K+-induced release was essentially unaffected by this toxin. Postnatal development of the D-[3H]aspartate release induced by veratridine was found to require 40-45 days, whereas release induced by K+ reached about 80% of maximum at postnatal day 22. K+-induced release appears to reach maturation when most hippocampal cells have been formed while veratridine-induced release probably requires completion of the neural circuit, involving also extensive sodium channel formation. These investigations were conveniently performed using a modified plastic culture box in which 24 slice systems can be studied simultaneously.

Relapses of idiopathic diffuse crescentic glomerulonephritis without immune deposits: report of 6 cases

Idiopathic diffuse crescentic glomerulonephritis without immune deposits is a variant of rapidly progressive glomerulonephritis which can account for up to 40% of crescentic nephritis. The prognosis may depend on both the severity of histological injury at presentation and the efficacy of treatment. Recent advances in therapy have improved the outlook further, and prolonged stable remissions with mild renal failure can occur which contrast with the previously common evolution towards end-stage renal failure within a few weeks. However, relapses in otherwise stable remission may be seen, and we describe a series of 6 acute relapses interrupting such prolonged remissions. The relapses were defined by clinical and histological means. This modification of the natural history of some crescentic glomerulonephritis may reflect new therapeutic strategies, and the relapses may reflect a cyclical nature to the disease evolution which was previously hidden by hemodialysis. The possibility of successive flares suggests that kidney biopsies should be repeated when a rapid deterioration of renal function occurs, since treatment such as high-dose steroids and/or plasma exchange can be again effective if started early.

Adenovirus type 3 infection with systemic manifestation in apparently normal children

Between July 1983 and February 1984, eight children with adenovirus Type 3 infection, proven by virus isolation from sputum, stool or nasopharyngeal swabs and a fourfold increase in complement fixation antibody titers against the virus, were treated in our department. All eight patients had fever lasting at least 7 days, hepatomegaly, diffuse pulmonary infiltrates and abnormal liver function tests. Seven of the patients exhibited dyspnea and pulmonary wheezing. Six of the patients developed changes in state of consciousness, and three had repeated convulsions. EEG patterns in three of the patients were compatible with encephalopathy. Other clinical manifestations included: follicular tonsillitis in two patients, diarrhea in two, pneumothorax in one, and shock with disseminated intravascular coagulation in one. The spectrum of adenovirus Type 3 infection reported here has been described previously only in the viral hemorrhagic fevers. This adenovirus Type 3 infection shares the potential for disseminated disease that has been described previously for Type 7, simulating Reye's syndrome.

Acute dystonic reaction to bethanechol--a direct acetylcholine receptor agonist

Bethanechol is a direct agonist of the acetylcholine receptor that was recently introduced in the therapy of gastro-oesophageal reflux. Acute dystonic reactions to bethanechol were observed in a 10-month-old infant who also demonstrated similar dystonic reactions to dopamine receptor blocking agents of two different classes. This first report of acute dystonic reaction to cholinergic agonists in human is in accord with the current theories of the rôle of acetylcholine and dopamine in the pathogenesis of acute dystonic reactions.