Common variable immunodeficiency syndrome with right aortic arch: a case report

BACKGROUND

Common variable immunodeficiency syndrome predominantly affects adults. It is characterized by low production of all the major classes of immunoglobulins. We report a case of common variable immunodeficiency syndrome with right aortic arch. An association of right-sided arch and common variable immunodeficiency syndrome has not been previously reported.

CASE PRESENTATION

A 41-year-old female patient presented with a history of recurrent pneumonia, sinusitis, otitis media, diarrhoea, cystitis since childhood. Biochemical and immunocytochemical analysis revealed common variable immunodeficiency syndrome and radiological evaluation confirmed right aortic arch and aberrant left subclavian artery.

CONCLUSION

Common variable immunodeficiency syndrome syndrome is a clinical entity that should be kept in mind in patients with recurrent infections of different sites.

Orbital pythiosis: a non-fungal disease mimicking orbital mycotic infections, with a retrospective review of the literature. Orbitale Pythiose: Eine nicht pilzbedingte, Orbitalmykose vortauschende Krankheit nebst Literaturubersicht

In the past decade there have been four well-documented cases of orbital pythiosis caused by Pythium insidiosum. All were recorded in apparently healthy children. Although pythiosis seems to be a rare infection in humans, we recently conducted a review of the medical literature to investigate misdiagnosed cases of orbital pythiosis in the past 100 years in children. To track putative cases of orbital pythiosis, we first identified orbital cases initially diagnosed as fungal infections. We were particularly interested in cases (a) involving apparently young healthy hosts, (b) the presence of hyaline, aseptate hyphal elements in the infected tissues, (c) the morphological features of the hyphal elements, (d) the presence of an eosinophilic granulomatous reaction with the Splendore-Hoeppli phenomenon around the mycelial elements, (e) resistance to antifungal therapy, (f) outcome after therapy, if any, and (g) cultural strategies. This study showed that indeed, there had been five other recorded cases of orbital infections, all in young children in the USA, with characteristics consistent with infections caused by P. insidiosum. The reports had described those cases of orbital-cranial-arterial diseases as patients with aspergillosis (one case), penicilliosis infection (one case), and zygomycosis (three cases). We reviewed those anomalous cases and discuss details about their clinical, pathologic, therapeutic, and etiologic evidence used to reclassify them as putative cases of orbital pythiosis.

Disseminated pythiosis in three horses

Three cases of equine subcutaneous pythiosis with dissemination to the internal organs were investigated. The subcutaneous lesions were observed on the mammary gland, nostrils and limbs of the infected horses. Histopathological analysis of the infected tissues revealed a strong eosinophilic reaction, with macrophages, mast cells and giant cells. Sparsely septated hyphal filaments of 4-6 microm diameter were identified in the center of the eosinophilic areas. Specific fluorescent antibody against Pythium insidiosum confirmed the hyphae in the infected tissues in three examined horses. In one of the three cases, the DNA sequences amplified from the infected subcutaneous tissues and internal organs, revealed that P. insidiosum's 18S SSU rDNA amplicons shared 100% identity with those sequences deposit in GenBank. This is the first report confirming by immunochemical and genetic techniques that P. insidiosum can disseminated from superficial to deep structures.

[Surgical treatment of creeping infections of the flexor foot tendons in diabetic patients]

The creeping infections of the flexor foot tendons are a common reason for amputation of limbs in diabetic patients. Usually the process starts from the fingers and spreads through their long flexors.

METHODS

Of the total of 149 operated patients, 49 underwent selective removal of the m. flexor hallucis longus tendon, and amputation of the 1st finger. The long flexors of the foot fingers were totally removed through a transmethatarsal amputation in 78 patients, and in 22 the long flexor tendons of the 4 lateral fingers were selectively removed through an oblique foot resection. After this type of surgical operations, limb amputation as a result of losing control over the suppurative-gangrenous process, became necessary in 7 patients.

CONCLUSIONS

The infection spreading through the long flexors of the foot fingers in diabetic patients is a serious surgical complication that can only be treated surgically. The method of selective resection and removal of the infected long flexors of the foot fingers allows to avoid the limb amputation in most patients. Following this type of surgical interventions the foot biomechanics and the steadiness of the patient is inconsiderably disrupted.

[Pathology of lung transplantation and molecular aspects of pathogenesis]

Lung transplantation has become an established therapy for patients with a variety of end stage pulmonary diseases during the last twenty years. Many complications can affect the lung after transplantation, e.g. preservation related injury, mechanical complications of surgery, acute or chronic (obliterative bronchiolitis) rejection, infection, drug toxicity, recurrent disease, de novo disease, lymphoproliferative disorder. The regulation of tissue inflammation and repair mechanisms involving components of the immune systems depends on a number of cell-cell interactions. Today, our understanding of this pathogenetic and functional network is still at the beginning. The numbers of molecules and factors involved are still increasing. Technical progress has introduced a lot of new molecular techniques (e.g. PCR, cDNA Microarray etc.) for analysis of transplant reaction. Nevertheless assessment of lung allografts is usually by transbronchial biopsy and less commonly by thoracoscopic or open lung biopsy. A minimum of five fragments of alveolated lung parenchyma is required. Biopsies are examined by routine haematoxylin and eosin stain, connective tissue or elastic stains and further special stains, immunohistochemistry and molecular techniques will be performed if required. In examining biopsies from lung allografts three critical points to assess are: a. the presence or absence of acute rejection or b. chronic rejection (obliterative bronchiolitis), and c. the identification of infection. Interpretation of the histology requires knowledge of the clinical and microbiological results. New molecular techniques could help to elucidate the pathogenesis of transplant reaction and provide new insights to facilitate the clinical diagnostics of allograft pathology.

[Transplantation-associated infections]

Transplantation-associated infections are caused by an infected transplanted organ or the endogenic or exogenic environment of the recipient in a state of induced immunodeficiency. The best therapy would be to reconstitute the immunodeficiency, but this is usually impossible as it endangers the transplanted organ. Thus, a specific, standardised anti-infectious therapy is needed even in the absence of clearly identified micro-organisms [bacteria (in two thirds gram-positive rods), parasites (in central Europe predominantly Toxoplasma), fungi (especially Candida spp. or Aspergillus spp.) or viruses (such as Parvovirus B19 and Cytomegalovirus)]. Origins of infection (e.g., hygiene), types of infection (e.g., reactivation), typical localisations, diagnostic tools (e.g., blood cultures, antigenic tests, PCR, CT, advantages and disadvantages of antibody assays) and possible therapies are briefly discussed. The take home messages are to avoid economy measures in microbial diagnostics and to use CMV-seronegative donors whenever possible.

The role of apoptosis in non-mammalian host-parasite relationships

It is clear that the roles of apoptosis in the interactions between the parasite and their non-mammalian hosts are multifaceted and highly dependent on individual associations between the two organisms involved. Whilst there are instances where both organisms appear to gain from the apoptotic mechanism induced, in the majority of cases apoptosis appears to favour only one of the parties. In the instances when the parasite benefits, the apoptosis has been related to infectivity and virulence, an interruption of the killing mechanism of the host, and liberation of the pathogen. However, there are occasions where the apoptotic process benefits the host, as controlled cell death has been associated with limiting the pathogen population, parasite migration within the host and, in some instances, actually killing the invading organism. Apoptosis thus appears to play several fundamental roles within the host-parasite relationship which is ultimately reflected in an effect on the host population either mediated through an alteration in host fecundity or reduction in host numbers. The next decade promises to be both exciting and productive with respect to our knowledge of the relationship between apoptosis in non-mammalian animals and infection. Over the last few years the information obtained from studies on the apoptotic process in mammals and invertebrates (i.e. C. elegans and Drosophila) have been effectively used to increase our understanding of the apoptotic process in other animals such as insects, fish and amphibians. Such knowledge has paved the way for extensive studies on the effect of infections to be carried out.

[Pathology of small intestine transplantation]

Small bowel transplantation is being increasingly performed to treat patients with irreversible intestinal failure or short bowel syndrome. Worldwide approximately 100 transplantations are currently performed per year. Technical advances and new immunosuppressive strategies adopted during the last 10 years have significantly improved the quality of live and survival rate of the patients. The 5-year survival rate is currently around 60%. However, the procedure still bears significant live threatening risks. Mayor problems include surgical complications like anastomotic leakage or peritonitis, acute allograft rejection, systemic infection and in later stages loss of graft function due to chronic rejection. Acute rejection is common after intestinal transplantation. It may occur any time after transplantation and is seen in 50%-80% of the patients. The characteristic changes are enterocyte apoptosis in the crypts, cryptitis and mononuclear cell infiltration with activated lymphocytes. Severe cases may reveal ulcerations or even sloughing and widespread exfoliation of the epithelium and are almost invariably associated with graft loss. The histopathological abnormalities may be patchy and occur in grossly normal mucosa. Therefore, multiple biopsies should be generally sampled for histology. Acute rejection must be distinguished from infections in particular opportunistic viral infections caused by Cytomegalovirus (CMV) or Adenovirus as well as from Epstein-Barr virus-related B-lymphocyte proliferations. Differential diagnosis also includes preservation injury and ischemia resulting in damage of the mucosal surface epithelium. Long-term graft function and survival are now increasingly determined by chronic rejection. The hallmarks of chronic rejection are obliterative arteriopathy of mesenterial vessels and progressive fibrosis of the transplant including its mesentery.

The grade of acute thymus involution in neonates correlates with the duration of acute illness and with the percentage of lymphocytes in peripheral blood smear. Pathological study

In various stressful conditions, the thymus is subjected to incidental involution, mostly due to the thymocytolytic effect of secreted glucocorticosteroids. The aim of this study was to examine acute thymic involution in sick neonates and to compare the morphological grade with some clinical and laboratory parameters. The influence of the illness on thymus tissue was investigated in 100 neonates who were treated and died in a neonatology intensive care unit. The preterm infants (n = 73) were born before the 37th week of gestation. Analysis of 57 placentas showed inflammation in 32% and circulatory disturbances in 23% of the cases. The causes of death were confirmed by autopsy: 35 were preterm infants with respiratory distress syndrome without infection, 22 were malformed, and 10 had birth trauma or asphyxia. In contrast, 29 of the preterm infants had an infection, mostly pneumonia or sepsis, and 4 of the term infants had such infections. Acute thymus involution was histologically graded (0-4) according to the method of van Baarlen (see text). Resting state (grade 0) was found in 25 of 38 neonates who lived <12 h. In 13 of 38 neonates who lived <12 h, thymus involution suggested prenatal stress. The grade of thymus involution related to the duration of illness (p < 0.001). Placental inflammation was associated with features of thymus involution (p < 0.048). Infection as a cause of death was connected to advanced thymus involution (p < 0.001). In preterm newborns, infection was more often connected with acute thymus involution than was respiratory distress syndrome (p < 0.003). Among the parameters measured in all available peripheral blood samples taken 24 h before death, only the lymphocyte count related to the grade of acute thymus involution (p < 0.05), with an increase in percentage of lymphocytes in peripheral blood smears from grade 0 to 2 and a decrease from grade 2 to 4. Although the white blood cell count is highly variable, a low percentage of lymphocytes might be a sign of advanced accidental thymus involution following acute stress.

WHIM syndrome: a genetic disorder of leukocyte trafficking

PURPOSE OF REVIEW

WHIM syndrome (the association of warts, hypogammaglobulinemia, recurrent bacterial infections, and 'myelokathexis') is a rare congenital form of neutropenia associated with an unusual immune disorder involving hypogammaglonulinemia and abnormal susceptibility to warts. In this review, we describe the clinical, laboratory and genetic features of WHIM syndrome.

RECENT FINDINGS

The identification of chemokine receptor CXCR4 as the causative gene of WHIM syndrome yields new interest in the study of this disease as a model for the comprehension of CXCR4 biology in humans and highlights the importance of the chemokine network for inducing effective immune responses and governing leukocyte trafficking.

SUMMARY

CXCR4 participates in several biological processes (bone marrow hematopoiesis, cardiogenesis, angiogenesis, neurogenesis) and is implicated in different clinical pathologic conditions (WHIM, HIV infection, tumor metastatization, autoimmunity). Pharmacologic agents that modulate CXCR4 expression/function are already available and promise a wide range of future clinical applications.

Male accessory gland infection: standardization of inflammatory parameters including cytokines

Assessment of infection of the male accessory glands is usually based on the search for white blood cells in different specimens to document an inflammatory reaction. This widely used practice allows to establish the diagnosis of inflammation in many cases. However, clinical symptoms do not always correlate with the presence or absence of white blood cells. This is particularly true for chronic prostatitis/chronic pelvic pain syndrome. In the last few years different research efforts have been made to look for markers of inflammation other than elements of the white blood cell line. Several studies suggest that humoral rather than cellular parameters are involved in male accessory gland infections. Substances such as reactive oxygen species, nerve growth factor and cytokines seem to be important not only in the pathogenesis of the inflammatory reaction but may also serve as diagnostic markers to indicate the presence of inflammation.

The damage-response framework of microbial pathogenesis

The late twentieth century witnessed the emergence of numerous infectious diseases that are caused by microorganisms that rarely cause disease in normal, healthy immunocompetent hosts. The emergence of these diseases shows that the existing concepts of pathogenicity and virulence do not take into account the fact that both the microorganism and the host contribute to microbial pathogenesis. To address this impediment to studies of host-microorganism interactions, we propose a new theoretical approach to understanding microbial pathogenesis, known as the 'damage-response' framework.

Role of peritoneal mesothelial cells in peritonitis

Background

Peritoneal mesothelial cells have a remarkable capacity to respond to peritoneal insults. They generate an intense biological response and play an important role in the formation of adhesions. This review describes these activities and comments on their relationship to surgical drainage, peritoneal lavage and laparostomy in the management of patients with peritonitis.

Methods and results

Material was identified from previous review articles, references cited in original papers and a Medline search of the literature. The peritoneal mesothelium adapts to peritonitis by facilitating the clearance of contaminated fluid from the peritoneal cavity and inducing the formation of fibrinous adhesions that support the localization of contaminants. In addition, the fluid within the peritoneal cavity is a battleground in which effector mechanisms generated with the involvement of peritoneal mesothelial cells meet the contaminants. The result is a complex mix of cascading processes that have evolved to protect life in the absence of surgery.

Conclusion

Future advances in the management of patients with severe peritonitis may depend upon molecular strategies that modify the activity of peritoneal mesothelial cells.

Kinetics of 99mTc-labeled interleukin-8 in experimental inflammation and infection

The cytokine interleukin-8 (IL-8) binds with high affinity to the CXCR1 and CXCR2 receptors on neutrophils. In previous studies, we showed that (99m)Tc-IL-8 could rapidly and effectively delineate foci of infection and inflammation in rabbit models of intramuscular infection, colitis, and osteomyelitis. Here, the in vivo kinetics and pharmacodynamics of (99m)Tc-IL-8 are studied in detail. A derivative of hydrazinonicotinamide (HYNIC) was used as a bifunctional coupling agent to label the protein with (99m)Tc.

METHODS

To address specificity of uptake of (99m)Tc-IL-8 in the abscess, uptake in turpentine-induced abscesses in neutropenic rabbits was compared with uptake in turpentine-induced abscesses in normal rabbits. The pharmacokinetics of (99m)Tc-IL-8 were studied in neutropenic rabbits and compared with those in normal rabbits. To investigate the interaction of (99m)Tc-IL-8 with blood cells in circulation in normal rabbits, the distribution of the radiolabel over circulating white and red blood cells and plasma was determined. The in vivo kinetics of (99m)Tc-IL-8 were studied by quantitative analysis of whole-body images acquired between 0 and 6 h after injection. The results of this analysis (in vivo biodistribution) were validated by ex vivo counting of radioactivity in dissected tissues.

RESULTS

The abscess uptake (percentage of injected dose per gram of tissue [%ID/g] +/- SEM) in immunocompetent rabbits (0.41 +/- 0.05) was 10 times higher than that in neutropenic rabbits (0.038 +/- 0.014), demonstrating specificity of the target uptake of (99m)Tc-IL-8. Abscess-to-muscle ratios +/- SEM were also 10 times higher (110 +/- 10 vs. 10 +/- 5). Lung and spleen uptake in normal rabbits was 3 times higher than that in neutropenic rabbits. The blood clearance of the radiolabel in neutropenic rabbits was similar to that in normal rabbits. In circulation, most of (99m)Tc-IL-8 (70%) was found in the plasma fraction. Less than one third was associated with red blood cells, and only a very low percentage (<2.5%) was associated with white blood cells. Image analysis revealed a gradually increasing abscess uptake over time up to >15%ID, which was confirmed by ex vivo gamma-counting of the infected muscle. The highest increase in uptake in the abscess was observed after 2 h following injection, when most of (99m)Tc-IL-8 was cleared from the blood, suggesting specific neutrophil-mediated accumulation of (99m)Tc-IL-8 in the abscess. Furthermore, region-of-interest analysis revealed that gradual accumulation of (99m)Tc-IL-8 in the abscess was accompanied by a simultaneous clearance of activity from the lungs, suggesting that neutrophil-associated (99m)Tc-IL-8 that was initially trapped in the lungs migrates to the abscess at later time points, favoring neutrophil-bound transportation from the lungs to the abscess.

CONCLUSION

Substantial support is given for the hypothesis that (99m)Tc-IL-8 localizes in the abscess, mainly bound to peripheral neutrophils. Accumulation in the abscess is a highly specific, neutrophil-driven process. As assessed by in vivo and ex vivo analysis, the total fraction that accumulates in the inflamed tissue is extremely high (up to >15 %ID) compared with that of other agents used for imaging infection and inflammation.

The Role of Growth Factors for Disease and Therapy in Diseases of the Head and Neck

Growth factors are a large family of polypeptide molecules that regulate cell division in many tissues by autocrine or paracrine mechanisms. Depending on what receptors are activated, growth factors can initiate mitogenic, antiproliferative, or trophic effects, that is, growth factors act as positive or negative modulators of cell proliferation. Therefore, growth factors do not only play an important role in embryonic development and adult tissue homeostasis, but also in pathological situations like infection, wound healing, and tumorigenesis. Consequently, the application of growth factors, or vice versa the application of substances which are directed against growth factors like antigrowth factor antibodies, may have therapeutic applications. This review provides a brief account of what we know regarding growth factors in otorhinolaryngology, particularly in the field of otology, wound healing, oncology, peripheral nerve regeneration, and rhinology.

Nailing a key assessment. Learn the significance of certain nail anomalies

Discover how a patient's fingernails can point out specific health problems.

Therapy of membranous nephropathy associated with malignancy and secondary causes

Membranous nephropathy (MN) most commonly is idiopathic, but secondary causes are common in children and in older adults. The most common secondary causes of MN in industrialized countries include malignancy and systemic lupus erythematosis. Infectious causes (hepatitis B, quartan malaria, schistosomiasis) remain the most common etiologies in endemic areas. In this article we describe the clinical approach to patients with MN associated with malignancy and other common secondary causes. Treatment of secondary MN generally targets the primary disease rather than the renal lesion.

Curbing activation: proprotein convertases in homeostasis and pathology

The proprotein convertases (PCs) are a seven-member family of endoproteases that activate proproteins by cleavage at basic motifs. Expression patterns for individual PCs vary widely, and all cells express several members. The list of substrates activated by PCs has grown to include neuropeptides, peptide hormones, growth and differentiation factors, receptors, enzymes, adhesion molecules, blood coagulation factors, plasma proteins, viral coat proteins, and bacterial toxins. It has become clear that the PC family plays a crucial role in a variety of physiological processes and is involved in the pathology of diseases such as cancer, viral infection, and Alzheimer's disease. Recent studies using PC inhibitors have demonstrated their potential as therapeutic targets. Despite the avalanche of in vitro data, the physiological role of individual PCs has remained largely elusive. Recently, however, knockout mouse models have been developed for furin, PC1, PC2, PC4, PC6B, LPC, and PACE4, and human patients with PC1 deficiency have been identified. The phenotypes range from undetectable to early embryonic lethality. The major lesson learned from these studies is that specific PC-substrate pairs do exist, but that there is substantial redundancy for the majority of substrates. To some extent, redundancy may be cell type and even species dependent.

An improved Pythium insidiosum-vaccine formulation with enhanced immunotherapeutic properties in horses and dogs with pythiosis

The immunotherapeutic properties of a new Pythium insidiosum-vaccine formulation (PIV), was evaluated in 18 horses and 6 dogs with proven pythiosis from different enzootic areas in the United States. All injected horses but one responded with a weak (=29 mm, n=3), a mild (30-90 mm, n=7) or a strong (=100 mm, n=7) inflammatory reactions at the site of injection. Three equines with weak or negative reactions at the injection site were not cured. Seven equines with strong reactions at their injection sites, however, were cured. Six of the eight horses with mild reactions were also cured. The remaining two equines responded at first but both relapsed and finally died of their infections. The PIV cured only two of the six dogs used in this study. The new PIV formulation cured 72% of the equines (P=0.048) and 33% of the dogs with pythiosis. Dogs with chronic disease (greater than two months) did not responded to immunotherapy. The finding of eosinophils, mast cells, IgE and precipitin IgG during pythiosis suggested that a T helper 2 (Th2) subset is in place during this disease. In cured horses, the eosinophilic reaction was substituted by lymphocytes and mononuclear macrophages (Th1). This and previous studies strongly support the hypothesis that an immune-modulation from a Th2 to a Th1 subsets may be in part responsible for the PIV's curative properties.

Standardized immune monitoring for the prediction of infections after cardiopulmonary bypass surgery in risk patients

BACKGROUND

Infections are the most common cause of late complications in cardiopulmonary bypass (CPB) surgery patients, and are difficult to predict. Here we studied the diagnostic value of a standardized immune monitoring program based on recent advances in flow cytometry (exact quantification of surface-marker expression) and cytokine determination (semiautomatic systems).

METHODS

CPB patients (56) at risk for complications (age >70 years and/or preoperative left-ventricular ejection fraction < 25 %) were classified into three groups: without (33), with suspected (14), and with confirmed (9) infection. Applying the Quantibrite trade mark -system, we daily quantified the expression of CD11b, CD64, CD71, CD86, and HLA-DR on monocytes/granulocytes. Furthermore, the ex vivo secretion of tumor necrosis factor (TNF)-alpha as well as the plasma interleukin (IL)-10 levels were determined by a semiautomatic system. Ex vivo elastase release was measured by enzyme-linked immunosorbent assay (ELISA).

RESULTS

All patients showed signs of granulocyte activation and monocyte deactivation. Monocytic HLA-DR and plasma IL-10 were the best markers to discriminate patients with infection from those without as early as day 1. Using a cutoff of 5792 HLA-DR molecules per cell, both sensitivity and negative predictive value for patients who developed microbiologically confirmed infection was 1.0, and the area under the curve (AUC) was 0.85.

CONCLUSIONS

Our data suggest that a standardized immune monitoring at day 1 might be useful for early discrimination of patients at elevated risk for infections.