Diagnosis of abdominal tuberculosis: sonographic findings in patients with early disease

OBJECTIVE

The diagnosis of abdominal tuberculosis is often difficult, because clinical manifestations and results of laboratory studies are nonspecific. If sonographic findings are sufficiently characteristic for diagnosis, sonography would be useful, especially in India, where abdominal tuberculosis is common and more expensive imaging techniques are not easily available. Accordingly, we performed sonography to establish the sonographic findings in cases of early tuberculosis in 56 patients with abdominal tuberculosis who had normal barium studies of the small bowel.

SUBJECTS AND METHODS

Fifty-six patients with clinical features suggestive of abdominal tuberculosis (history of fever, abdominal pain, and weight loss) with no history of intestinal obstruction and normal barium studies of the small bowel had abdominal sonography. All sonograms were independently assessed by three radiologists, and the findings were tabulated by consensus. Diagnosis of tuberculosis was confirmed by sonographically guided biopsy of mesenteric lymph nodes in 19 patients, analysis of aspirated ascitic fluid in 12, and response to antituberculous chemotherapy in 25. Sonography was repeated 1, 3, 6, and 12 months after antituberculous chemotherapy was begun. Abdominal sonograms were also performed in 30 healthy volunteers, and measurements of mesenteric thickness were recorded. The mesenteric thickness was statistically compared in two groups of patients: patients at presentation with patients at the end of antituberculous chemotherapy and patients at presentation with healthy individuals.

RESULTS

The mesenteric thickness in healthy individuals ranged from 5 to 14 mm. Sonographic findings in all patients with abdominal tuberculosis included an echogenic thickened mesentery (> or = 15 mm) with mesenteric lymphadenopathy. Other findings were dilated small bowel loops in 38 patients, minimal ascites in 17, matted small bowel loops in five, and omental thickening with altered echogenicity in three. Regression of these changes was noted on follow-up of all patients undergoing treatment.

CONCLUSION

The characteristic sonographic features of early abdominal tuberculosis are mesenteric thickness of 15 mm or more and an increase in the mesenteric echogenicity (due to fat deposition), combined with mesenteric lymphadenopathy. Presence of dilated small bowel loops and ascites further substantiate the diagnosis.

A comprehensive analysis of the distribution of FGF-2 and FGFR1 in the rat brain

We have examined the cellular distribution of both FGF-2 and FGFR1 immunoreactivity and their mRNAs throughout the normal adult rat brain in order to reconcile numerous disparate findings in the published literature. The results confirm a widespread distribution of FGF-2 and FGFR1 in the rat brain, and different regions express distinct patterns of FGF-2 and FGFR1 mRNA and protein: neuronal and non-neuronal cells show different subcellular distributions that vary according to the area where they are located. The intensity of the staining and hybridization also varies according to the loci examined and the cell type involved. Astrocytes contain the highest levels of FGF-2 and FGFR1 mRNAs, and characteristically, possess high levels of immunoreactive FGF-2 within the nucleus. Amongst non-neuronal cells, oligodendrocytes do not synthesize or contain significant levels of FGF-2 immunoreactivity however, they do express FGFR1 mRNA. In these cells, immunoreactive FGFR1 is mainly associated with the myelin sheaths of neuronal fibers. In ventricular systems, ependymal cells synthesize and contain immunoreactive FGFR1. In contrast, only cells lining the lateral wall of the IIIrd ventricle express FGF-2 mRNA. Subependymal cells contain high levels of both FGF-2 and FGFR1 immunoreactivity. Neurons express low levels of FGF-2 mRNA and immunoreactive FGF-2 is localized predominantly to the perikaryon. However, selected populations of neurons, such as CA2 field of the hippocampus, show high levels of FGF-2 mRNA, in which the nucleus is strongly immunopositive. Similarly, high levels of FGFR1 mRNA are localized to select populations of neurons (e.g. amygdala). FGFR1 immunoreactivity is mainly associated with myelinated fiber tracts (e.g. striatum), and some neurons show immunoreactivity in the perikaryon (e.g. hippocampus), the nucleus (e.g. mesencephalic trigeminal nucleus), or in axonal projections (e.g. hypothalamus). Remarkably, in many of the areas studied, FGF-2 and FGFR1 mRNA and/or their translated protein do not co-localize in neurons (e.g. neo-cortices) or even in the same regions of the brain (e.g. substantia nigra). In other instances, mRNAs for both FGF-2 and FGFR1 colocalize (e.g. supraoptic nucleus). The brain, in contrast to peripheral tissues, contains high levels of FGF-2 and actively expresses its gene under normal physiological conditions. The highly specific anatomical distribution of immunoreactive FGF-2 in neuronal and non-neuronal brain cells, supports the notion that it plays a multifunctional role in the CNS under normal physiology. By correlating the localization and the synthesis of FGF-2 and one of its high affinity receptors, FGFR1, in the CNS, it should be possible to obtain a better understanding of the roles of FGF-2 in normal and pathological conditions.

Type 3 lodothyronine deiodinase: cloning, in vitro expression, and functional analysis of the placental selenoenzyme

Type 3 iodothyronine deiodinase (D3) catalyzes the conversion of T4 and T3 to inactive metabolites. It is highly expressed in placenta and thus can regulate circulating fetal thyroid hormone concentrations throughout gestation. We have cloned and expressed a 2.1-kb human placental D3 cDNA which encodes a 32-kD protein with a Km of 1.2 nM for 5 deiodination of T3 and 340 nM for 5' deiodination of reverse T3. The reaction requires DTT and is not inhibited by 6n-propylthiouracil. We quantitated transiently expressed D3 by specifically labeling the protein with bromoacetyl [125I]T3. The Kcat/Km ratio for 5 deiodination of T3 was over 1,000-fold that for 5' deiodination of reverse T3. Human D3 is a selenoenzyme as evidenced by (a) the presence of an in frame UGA codon at position 144, (b) the synthesis of a 32-kD 75Se-labeled protein in D3 cDNA transfected cells, and (c) the presence of a selenocysteine insertion sequence element in the 3' untranslated region of the mRNA which is required for its expression. The D3 selenocysteine insertion sequence element is more potent than that in the type 1 deiodinase or glutathione peroxidase gene, suggesting a high priority for selenocysteine incorporation into this enzyme. The conservation of this enzyme from Xenopus laevis tadpoles to humans implies an essential role for regulation of thyroid hormone inactivation during embryological development.

Unusual radiological manifestations of Lemierre's syndrome: a case report

Lemierre's syndrome is an uncommon clinical entity characterized by oropharyngeal infection followed by septic thrombophlebitis of the jugular vein with embolization to the lungs and other organs. The organism is a gram-negative anaerobic bacterium, Fusobacterium necrophorum. We report a case of Lemierre's syndrome in an 8-year-old child who presented with septic arthritis of the left hip joint. Roentgenograms and computed tomography demonstrated gas in the joint and adjacent soft tissues, along with a dislocated hip. Sonography of the neck coupled with the colour Doppler technique did not reveal any abnormality in the jugular veins. A blood culture grew Fusobacterium necrophorum, confirming the diagnosis of Lemierre's syndrome.

Pulmonary metastasectomy

Between 1988 and 1994, 24 patients underwent 32 procedures for pulmonary metastases. Primary tumours were gastrointestinal, malignant melanoma, osteogenic sarcoma, renal cell carcinoma, head and neck cancer and finally testicular carcinoma. Age ranged from 16 to 78 years, with a female/male ratio of 7/17. Pulmonary metastasectomy was performed in 9 cases through median sternotomy, in 21 cases through thoracotomy and in 2 cases by thoracoscopy. In 9 cases repeated resection was necessary. Overall mortality was 0% (95% confidence limits are 0.00 +/- 14.25). Computed tomography of the chest in combination with tumour markers, were most important during follow-up to detect recurrent disease. The overall 5-year actuarial survival and disease-free survival were 0.56 +/- 0.17 and 0.30 +/- 0.14 respectively. With regard to testicular carcinoma 5-year actuarial survival was 100%. Pulmonary metastasectomy is a recommended procedure in the treatment of selected patients with metastatic pulmonary disease. Resections should be as conservative as possible and if necessary, repeated. In our study this procedure proved especially effective in case of testicular carcinoma.

Relationship between myelin sheath diameter and internodal length in axons of the anterior medullary velum of the adult rat

Relations between myelin sheath diameters and internodal lengths were measured in whole mounts of osmium stained intact anterior medullary velum (AMV) from glutaraldehyde perfused adult rats. The AMV is a sheet of CNS tissue which roofs the IVth ventricle and contains fascicles of myelinated fibres which arise mainly from the nucleus of the IVth cranial nerve. These fibers displayed a broad range of myelin sheath external diameters and internodal lengths, from < 1-12 microns and 50-750 microns, respectively. Myelin sheath external diameter was a measurement of the axonal diameter plus the thickness of its myelin sheath, while internodal length was measured as the distance between consecutive nodes. There was a broadly linear relationship between myelin sheath diameters and internodal lengths, with the smaller diameter sheaths tending to have shorter internodes than the larger. However, the correlation was weak and for any given diameter myelin sheaths displayed considerable variation in their internodal lengths. The smallest diameter myelin sheaths, < 4 microns, consistently had shorter internodes than predicted by a linear regression and, in an analysis of consecutive internodes in single fibres, the slope was flattened in fibres with a diameter > 4 microns. Our results indicated that small and large calibre fibres may have different myelin sheath diameter-internodal length interrelations.

Orbital hydatid cysts: sonographic and CT appearance

Two cases of unilateral proptosis due to orbital hydatid cysts were evaluated by ultrasound and computed tomography. Image morphology of this rare disease is presented.

Biochemical subtypes of oligodendrocyte in the anterior medullary velum of the rat as revealed by the monoclonal antibody Rip

Oligodendrocytes were studied in the anterior medullary velum (AMV) of the rat using the monoclonal antibody Rip, an oligodendrocyte marker of unknown function. Confocal microscopic imaging of double immunofluorescent labelling with antibodies to Rip and carbonic anhydrase II (CAII) revealed two biochemically and morphologically distinct populations of oligodendrocyte which were either Rip+CAII+ or Rip+CAII-. Double immunofluorescent labelling with Rip and myelin basic protein (MBP) or glial fibrillary acidic protein (GFAP) provided direct evidence that Rip-labelled cells were phenotypically oligodendrocytes and confirmed that Rip did not recognise astrocytes. Oligodendrocytes which were Rip+CAII+ supported numerous myelin sheaths for small diameter axons, whilst Rip+CAII- oligodendrocytes supported fewer myelin sheaths for large diameter axons. Morphologically, Rip+CAII+ oligodendrocytes corresponded to types I or II of classical nomenclature, whilst Rip+CAII- oligodendrocytes corresponded to types III and IV. The results demonstrated a biochemical difference between oligodendrocytes which myelinated small and large diameter fibres.

Healing of osteoporotic vertebral compression fractures following cure of Cushing's syndrome

Reversibility of gross radiologically manifest steroid-induced osteoporosis is disputable. A young boy with endogenous Cushing's syndrome with severe osteoporosis, demonstrating satisfactory recovery of osteoporotic changes within 2 years after cure of Cushing's syndrome, is described.

Ultrasonography, computed tomography and percutaneous intervention in acute pancreatitis: a serial study

Fifty-seven patients (45 males, 12 females) with a clinical diagnosis of acute pancreatitis were serially evaluated by ultrasonography (US) and computed tomography (CT). Thirty patients had a single study, 18 had one follow-up study while 9 had two follow-up studies. The aetiology was gallstone disease in 26% of patients and a history of chronic alcohol abuse in only 16%. No cause could be identified in 47% of patients; 22% of US scans were unsatisfactory for the evaluation of pancreas whereas CT was uniformly satisfactory. Peripancreatic inflammation was detected in only 29% patients on US compared with 91% on CT. Pancreatic abscesses were detected in 8 patients on CT and gas was present in all of them. Fourteen patients underwent guided interventional procedures (US, 12; CT, 2). On follow up after 3 months, worsening of inflammation was detected in 11% patients on CT, which was not detected on US. It is concluded from this study that CT is far superior to US in the evaluation of acute pancreatitis, detection of peripancreatic inflammation and its extension into the retroperitoneal compartments and mesentery, and also for the evaluation of fluid collections, haemorrhage and abscesses. However, US provides easy guidance for percutaneous interventional procedures and can be used for follow-up scans.

Effect of antagonists on DNA binding properties of the human estrogen receptor in vitro and in vivo

Functional analyses, performed with the estrogen receptor (ER) isolated from different sources or produced with various expression systems, led to contradictory results concerning the role of estrogen (E2) and antiestrogens in ER DNA binding. Here we report the DNA-binding properties of the human ER and show that the wild type ER (HEG0) binds in vitro to an estrogen response element (ERE) as a dimer, irrespective of the presence or absence of estrogen. We also show that the two antihormones, 4-hydroxytamoxifen (OHT, a partial ER agonist) and ICI 164,384 (a pure antagonist) do not impair HEG0 dimerization and DNA binding in vitro. Exposure of HEG0 to elevated temperature (37 C) in vitro results in a much faster reduction of its binding capacity to an ERE in the absence of ligand or in the presence of ICI 164,384 than in the presence of either E2 or OHT. The Gly to Val mutation at amino acid 400 present in the human ER that we initially cloned (HE0), is responsible for an even faster heat inactivation of unliganded receptor compared with HEG0 and largely accounts for the previously observed in vitro ligand-dependent DNA binding of ER. We also show that, as previously observed for OHT, ICI 164,384 does not prevent ER binding to an ERE in vivo, even though ICI 164,384 acts as a pure antagonist for transcriptional activation by ER. We discuss these results in the context of a ligand-dependent interaction between the C-terminal region E, which contains the ligand-binding domain, and the N-terminal A/B region, which contains the activation function AF-1.

Neuroendocrine primary small cell carcinoma of the breast. Report of a case and review of the literature

One case of breast neuroendocrine primary small cell carcinoma with light microscopic and immunohistochemical findings is reported. The patient died of unrelated disease 21 months after diagnosis and treatment by modified radical mastectomy, radiotherapy and subsequent chemotherapy. Immunohistochemical studies revealed cytokeratin and neuroendocrine markers (chromogranin, neuron-specific enolase) immunostaining on tumoral cells. Expression for neuropeptides (met-enkephalin, leu-enkephalin, beta-endorphin) and CALLA antigen was found. Based on this case report and six other previously reported cases, breast neuroendocrine primary small cell carcinoma appears to be a very aggressive tumor for which no firm conclusions regarding treatment can be drawn.

Extensive regeneration in vitro by early embryonic neurons on immature and adult CNS tissue

The failure of axon regeneration in the injured adult CNS has been ascribed to axon growth inhibitory molecules expressed by the resident glial cell populations, especially oligodendrocytes. Unlike their adult counterparts, however, early embryonic neurons are able to send lengthy axons through myelinated fiber tracts when transplanted into the adult brain. One explanation is that they have yet to express receptors for factors that inhibit the growth of older neurons. To test this possibility, we have used the cryoculture technique to study the regeneration of rat central and peripheral neurons, over a developmental period that encompasses the stages before, during, and after target contact, when cultured on either unmyelinated (neonatal) or myelinated (adult) optic nerve tissue sections. Early embryonic (days 14-15) retinal ganglion cells extended neurites on neonatal optic nerve, but few grew on adult optic nerve. In the case of early embryonic dorsal root ganglion neurons, however, neurite outgrowth on either neonatal optic nerve or on adult optic nerve was extensive. This response declined sharply with age. In contrast, neurite outgrowth by dorsal root ganglion neurons on laminin substrata remained relatively constant (> 80% extended neurites) over the same period. This suggests that (a) inhibition of neurite outgrowth within the optic nerve is mediated not only by oligodendrocytes, but also by molecules expressed prior to the onset of myelination; (b) neurons acquire receptors for these inhibitors only late in embryonic development; (c) differences exist between developing central and peripheral neurons in the response to myelin-associated axon-growth inhibitors.

A comparison of adjustments to urinary diversions: a pilot study

Cystectomy with urinary diversion is the treatment for many patients with bladder cancer. The ileal conduit continues to be an effective solution to the diversion problem, but it brings with it problems related to management and body image. The development of the orthotopic neobladder to the urethra is a recent effort to return the body to the most natural structure and function. This development, however, brings its own set of problems to be overcome. The purpose of this exploratory study was to examine the adjustments reported by male patients with ileal conduits and neobladder replacements. A questionnaire was mailed 10 to 30 months after operation to 30 patients who underwent ileal conduit and neobladder surgery. The questionnaire explored sickness-related dysfunction and adjustments the patients had to make after operation. Twenty-three patients (12 with ileal conduits and 11 with neobladders) responded to the questionnaire. There were no statistically significant differences in sickness impact scores between the ileal conduit and neobladder groups. Few patients with ileal conduits reported problems with the device. All the patients with neobladders reported some continued incontinence, primarily at night. All the patients reported erectile dysfunction, but few had sought treatment for this problem. The patients with ileal conduits reported impact on their social activities more frequently. Future research with a larger sample is needed, but this pilot study suggests that health care workers can do more to facilitate the adjustment to loss of sexual function and social interaction.

Toxicity of antibiotics and antifungals on cultured human corneal cells: effect of mixing, exposure and concentration

Toxic effects of topical drugs may be masked by manifestations of the disease they cure. The toxicity of drug mixtures has not been thoroughly studied. We therefore investigated cytopathic effects on primary cultures of human corneal cells of six topical antimicrobials singly and in combinations of any two, to determine the combined toxicity ranking and the interaction between duration of exposure and concentration. Preconfluent cultures were exposed to fixed dilutions of single drugs, or to equal-dilution mixtures of two drugs, for 7 and 14 days. Diminishing concentrations of single drugs were applied sequentially to cultures for 14 days. The number of metabolically competent cells was assessed by measuring hexosaminidase and total protein. Toxic effects depended on substance, concentration and exposure. The scale of toxicity determined for single drugs after 7 days of exposure was: gentamicin > econazole > or = methicillin > or = clotrimazole > or = miconazole > or = chloramphenicol. After 14 days this order changed: in particular chloramphenicol showed a highly increased toxicity. The order of diminishing effects was: gentamicin > chloramphenicol > or = methicillin > miconazole > econazole > clotrimazole. A clear reduction in cytopathic effects was observed when drug concentration was decreased progressively only in cultures treated with gentamicin or methicillin. All drug combinations were more toxic than their components at equal dilution. Combinations containing chloramphenicol ranked most toxic overall, those containing econazole least. A tapering off combination regime did not improve cell survival. These in vitro toxicity data complement clinical studies and suggest ways in which topical drugs can be chosen to minimise toxic effects to corneal surface.

Ossified gastric leiomyoma in a child: a case report

Calcification in gastric leiomyoma (GLM) is extremely rare. Eleven cases have been reported so far, all in adults. We report the first ossified GLM in a 2-year-old child. A number of unusual clinical and imaging features are discussed.

Coordinated pattern of expression and localization of insulin-like growth factor-II (IGF-II) and IGF-binding protein-2 in the adult rat brain

Insulin-like growth factors (IGFs) have numerous actions on neuronal and glial cell function in vitro, although their in vivo roles within the central nervous system (CNS) remain undefined. Levels of IGF-II are high in most rat tissues before the third postnatal week, but rapidly decrease thereafter, except in the brain and spinal cord, where elevated titers are present in the adult. This suggests a function of IGF-II within the CNS. IGF-binding proteins (IGFBPs) modify the type 1 IGF receptor-mediated activity of IGFs, thereby regulating the activities of IGF-II in the CNS. In this study, we use a ribonuclease protection assay, in situ hybridization, and immunohistochemistry to demonstrate that IGF-II and one of the major CNS binding proteins, IGFBP-2, show a striking congruency in their anatomical pattern of expression and localization throughout the adult rat brain. Both proteins are synthesized predominantly in the leptomeninges, choroid plexus, and parenchymal microvasculature, but become localized, remote from the site of synthesis, in the myelin sheaths of individual myelinated axons and in all of the myelinated nerve tracts in the brain, which presumably represents the site of IGF-II bioactivity. The spatial disparity between sites of synthesis and sites of bioactivity suggests a key role for IGFBP-2 in the regulation of IGF-II bioavailability within the brain.

Astrocyte associations with nodes of Ranvier: ultrastructural analysis of HRP-filled astrocytes in the mouse optic nerve

Astrocytes are implicated in the function of nodes of Ranvier because their perinodal processes form contacts with the axonal membrane at nodes. We have filled astrocytes iontophoretically with horseradish peroxidase in the intact mouse optic nerve to resolve the precise relationship between perinodal processes and astrocyte three dimensional structure. We confirm that nodal contacts were formed either by single processes which almost completely enveloped nodes, or by delicate, finger-like projections from larger processes which made discrete nodal contacts. A single perinodal process can form multiple contacts with a node and nodes were contacted by processes from more than one astrocyte. Perinodal processes emanated from larger processes, which terminated as end-feet on blood vessels and at the pia, as well as collateral branches which subsequently ended at nodes; these latter may specifically subserve nodes. Perinodal contacts were also formed directly by the soma and cytoplasmic expansions of the cell body. Both primary processes and collateral branches formed multiple associations with nodes which often appeared in clusters. Thus, all astrocytes formed multiple contacts with nodes, blood vessels and the subpial glia limitans. We conclude that perinodal processes are not formed by a specialized astrocyte in the mouse optic nerve.

Three-dimensional morphology of astrocytes and oligodendrocytes in the intact mouse optic nerve

The three-dimensional morphology of astrocytes and oligodendrocytes was analysed in the isolated intact mature mouse optic nerve, by correlating laser scanning confocal microscopy and camera lucida drawings of single cells, dye-filled with lysinated rhodamine dextran or horseradish peroxidase, respectively. These techniques enabled the entire process field of single dye-filled cells to be visualized in all planes and resolved the fine details of glial morphology. Morphometric analysis showed that the processes of all astrocytes had branches ending at the pial surface, on blood vessels, and freely in the nerve; branches ending in the nerve were described to end at nodes of Ranvier in the accompanying paper. Astrocytes were classified into a single morphological population in which each cell subserved multiple functions. The results of this study do not support the contention that astrocytes can be subdivided into two morphological and functional subtypes, namely type-1 and type-2, which have process ending either at the glia limitans or at nodes, respectively. Three-dimensional analysis of oligodendrocyte units, defined as the oligodendrocyte, its processes and the axons it ensheaths, showed the provision of single myelin segments for an average of 19 nearby axons (range 12-35) with a mean internodal length of 138 microns (range 50-350 microns). Mouse optic nerve oligodendrocytes were a homogeneous population and were markedly similar to those in the rat optic nerve. The results of our analysis of oligodendrocyte morphology are consistent with the view that the number and internodal length of myelin sheaths supported by a single oligodendrocyte are related to the diameter of the ensheathed axons.

Cushing's disease: pituitary imaging

Fourteen patients with adrenocorticotropic hormone (ACTH)-dependent hypercortisolism underwent pituitary scanning with computed axial tomography (CT) and magnetic resonance imaging (MRI). Computed tomography revealed pituitary macroadenomas in two patients, pituitary hyperplasia in one and a suspicion of pituitary microadenoma in one. Thirteen patients underwent MRI. One with a macroadenoma diagnosed on CT did not undergo MRI. The MRI revealed a pituitary macroadenoma in one, microadenoma in three and hyperplasia in two cases. Magnetic resonance imaging following gadolinium diethylene triamine penta acetic acid (gd-DTPA) enhancement revealed four more pituitary microadenomas. All patients who had pituitary adenomas (micro and macro) and hyperplasia underwent trans-sphenoidal pituitary surgery. One of the two patients, who had an enlarged pituitary on imaging but no demonstrable adenoma, was found to have a microadenoma at surgery. Patients with ACTH-dependent hypercortisolism should undergo MRI of the pituitary gland to identify/localize corticotroph pituitary adenomas. The study should include gd-DTPA enhancement in cases where the scan is normal.