Pregnancy in an azoospermic patient with markedly elevated serum follicle-stimulating hormone levels

OBJECTIVE

To assess the possibility of achieving a pregnancy in an azoospermic patient with markedly elevated serum FSH level.

DESIGN

A case report.

SETTING

In vitro fertilization program at the Instituto Valenciano de Infertilidad.

PATIENT

An azoospermic patient with small testes and serum FSH level (38.7 mIU/mL) higher than three times normal. Testicular biopsy revealed Sertoli cell-only syndrome with focal spermatogenesis.

INTERVENTIONS

Intracytoplasmic microinjection of testicular tissue-extracted spermatozoa.

MAIN OUTCOME MEASUREMENTS

Fertilization rate, cleavage rate, clinical pregnancy.

RESULTS

Eight of 11 (73%) intact oocytes showed two pronuclei. All of them cleaved normally. Four embryos were replaced into the uterine cavity and the other four were cryopreserved. A twin clinical pregnancy was achieved.

CONCLUSION

Spermatozoa may be present in testicular biopsy specimens of azoospermic patients with severe spermatogenic failure despite markedly elevated serum FSH level. These patients can be fertile after intracytoplasmic testicular sperm microinjection.

Nosocomial and community-acquired Legionella pneumonia: clinical comparative analysis

Previous reports have suggested that nosocomial and community Legionella pneumonia cases are similar. However, community and hospital characteristics, such as aquatic environment, antibiotic pressure (usage) and populations, are quite different, leading to the suspicion that Legionella infection may differ in the two settings. Univariate and multivariate analyses were performed to compare demographic data, risk factors, clinical, radiological and outcome data between 125 nosocomial and 33 community-acquired cases of Legionella pneumophila infection. Patients in the nosocomially acquired Legionella pneumonia (NALP) group were older than those in the community-acquired Legionella pneumonia (CALP) group. Univariate analysis showed that smoking habit, cough, thoracic pain, and extrapulmonary manifestations were more prevalent in the CALP group, whilst chronic lung disease and cancer were more prevalent in the NALP group. Moreover, patients in the NALP group were more likely to have received oxygen and corticosteroid therapy and also to have altered creatinine values than patients in the CALP group, whilst more patients in the latter group had altered alanine amino-transferase values. However, multivariate analysis failed to confirm most of these differences. Smoking habit and blood creatinine levels were the only variables remaining significant. In conclusion, demographic, clinical, laboratory, radiological and outcome data in nosocomial and community-acquired Legionella pneumonia are quite similar.

Chronic hepatitis C in alcoholic patients: prevalence, genotypes, and correlation to liver disease

BACKGROUND

Only one-fifth of chronic alcoholic patients develop chronic liver disease in spite of continuous alcohol abuse. Hepatitis C has been proposed to be one of several suggested factors contributing to the development of liver disease.

METHODS

In 201 consecutive chronic alcoholic patients admitted to the hospital for detoxification, antibodies to hepatitis C virus (HCV) were determined, using second-generation enzyme-linked immunosorbent assay (ELISA) and recombinant immunoblot assay (RIBA) tests. Sera from patients with antibodies were tested with polymerase chain reaction (PCR) to detect HCV RNA and subsequently genotyped.

RESULTS

Twenty-nine patients (14%) were positive in the ELISA and RIBA tests. HCV RNA was detected in 23 of the 29 (79%); 21 could be genotyped. Previous intravenous drug abuse was present in 18 of 29 (58%) in the positive group versus 3 of 172 (2%) in the negative group (p < 0.001), whereas the prevalence of previous blood transfusions did not differ between the groups. In one-third of the positive cases no obvious route of transmission was found. On the basis of clinical and biochemical variables and, if available, histology, altogether 6 of 29 (21%) HCV-positive patients were classified as having severe liver disease as compared with 12 of 172 (7%) HCV-negative patients (p < 0.05). HCV-positive patients with liver disease were younger than HCV-negative patients with liver disease (p < 0.05).

CONCLUSIONS

Hepatitis C virus infection is common among chronic alcoholic patients in Stockholm, especially among patients with a history of intravenous drug abuse. To confirm ongoing infection, detection of HCV RNA is necessary. This infection seems to be a factor contributing to the development of liver disease in alcoholic patients.

Flat neoplastic lesions of the colon and rectum detected by high-resolution video endoscopy and chromoscopy

Because small flat colorectal neoplastic lesions (i.e., flat adenomas and flat adenocarcinomas) may be as translucent as the surrounding mucosa, they can remain undetected at conventional endoscopy. By combining high-resolution video endoscopy and chromoscopy, we detected 109 colorectal flat neoplastic lesions in 55 of 232 patients studied. Forty-three (78%) of the 55 patients with flat neoplastic lesions were over 60 years of age. No flat neoplastic lesions were seen in patients under 40 years of age. Flat neoplastic lesions were more frequent in men (35%) than in women (15%). Seventy-seven (71%) of the 109 flat neoplastic lesions measured 0.5 cm or less, 23 (21%) between 0.6 and 1.0 cm, and 9 (8%) more than 1.0 cm. Low-grade dysplasia and high-grade dysplasia were found in 94 (86%) and 13 (12%) of the flat neoplastic lesions, respectively. Adenocarcinoma was diagnosed in 3 (3%) flat lesions: 1 (1%) carcinoma originating in a flat adenoma and 2 (2%) adenocarcinomas without recognizable adenomatous elements. No adenocarcinomas were seen in lesions measuring 1.0 cm or less. Fourteen flat neoplastic lesions had a central depression at endoscopy. Flat neoplastic lesions with central depression more frequently showed high-grade dysplasia (43%) than did flat neoplastic lesions without central depression (7%). Central depression in flat neoplastic lesions should be considered a possible endoscopic marker for severe dysplasia. Our results suggest that flat neoplastic lesions occur more frequently than previously reported in Scandinavia. Flat adenomas may play an important role in the histogenesis of colorectal cancer.

Interferon-alpha/beta can impede development of carcinogen-induced squamous-cell tumors in the esophagus of C57B1 mice

The effect of treatment with murine interferon-alpha/beta preparations on diethylnitrosamine-induced squamous-cell tumors in the esophagus of C57B1 mice was investigated. Diethylnitrosamine was administered in the drinking water for 18 weeks. Interferon was given intraperitoneally during the same 18 weeks or from the end of the period of carcinogen exposure until termination of the experiment. In mice given interferon and diethylnitrosamine synchronously, a significantly lower tumor index (number of tumors/cm of esophageal mucosa) was observed as compared to all control groups. Treatment with interferon after the administration of the carcinogen was terminated had no effect on the appearance of tumors. These data suggest that interferon therapy can exert certain effects on carcinogenesis.

[The validity of the separate determination of total cholesterol in the primary prevention of coronary risk]

BACKGROUND

The aim of this study was to validate total cholesterol (TC) determination in the primary prevention of coronary risk and evaluate the prevalence of low HDL cholesterol (HDL-C) levels at the different TC cut-off points to thereby determine the TC level at which HDL-C determination is of interest.

METHODS

The atherogenic index was used as the reference method in TC evaluation with the values of low HDL-C levels being evaluated at the following TC cut-off points: 160, 180, 200, 220, 240, 250, and 300 mg/dl (4.44; 4.66; 5.18; 5.70; 6.22; 6.48; 7.77 mmol/l). According to the results of the Framingham study the atherogenic index or the existence of low HDL-C levels were considered as abnormal. The sample included 4,162 workers from the province of Alicante (Spain) selected by consecutive sampling and opportunistic search in January and February, 1993. Validity was calculated with confidence interval of 95%.

RESULTS

The atherogenic index was high in 43.7% of the sample, ranging from 6% in the population with TC lower than 160 mg/dl (4.14 mmol/l) to 76.4% in those oscillating between 250-299 mg/dl (6.48-7.76 mmol/l). Low HDL-C levels were detected in 20.1% with a prevalence ranging from 38.8% in those with a TC of less than 160 mg/dl (4.14 mmol/l) to 11.9% in those with TC > or = 250 mg/dl (> or = 6.48 mmol/l). The cut-off points for low TC had high sensitivity (S) and low specificity (SP) (160 mg/dl [4.14 mmol/l]: S = 91.1%, SP = 11.5%; 180 mg/dl [4.66 mmol/l]: S = 95.2%, SP = 30.2%). The highest TC points presented very low S and very high SP (250 mg/dl [6.48 mmol/l]: S = 46.3%, SP = 87.7%; 300 mg/dl [6.48 mmol/l]: S = 7.4%, SP = 97%).

CONCLUSIONS

The HDL-cholesterol should be determined in people with a total cholesterol of less than 200 mg/dl (5.18 mmol/l) since, in this group there is an important percentage of individuals with an altered atherogenic index and low HDL-C levels.

The significance of mucosal staining for the endoscopic diagnosis of chronic esophagitis as assessed in biopsy findings

A total of 115 patients with clinical signs of esophagitis were examined by endoscopy and mucosal biopsy combined with Lugol solution. Overall, 175 mucosal areas (105 stained and 70 unstained) were subjected to histopathological examination. The correlation between the staining properties of the esophageal mucosa and the histopathological diagnosis resulted in a diagnostic sensitivity of 51.9%, a specificity of 70.2%, a positive predictive value of 60.0% and a negative predictive value of 62.9% for Lugol combined endoscopy. Lugol combined endoscopy did not appear to result in any improvement in the diagnosis or staging of reflux esophagitis in our study.

Flat adenoma-adenocarcinoma sequence in the colon of rats

PURPOSE

As there is an increased awareness of the existence of a "flat adenoma-adenocarcinoma sequence" in the colonic mucosa of human subjects, the aims of the study were to assess whether flat colonic adenocarcinomas in rats are also preceded by flat adenomas, as is reported in humans, and to determine the frequency of flat lesions compared with exophytic lesions in the colon of rats.

METHOD

The colonotropic carcinogen 1,2-dimethylhydrazine was injected subcutaneously in 300 Sprague-Dawley rats for 27 weeks.

RESULTS

A total of 358 tumors developed in 278 of the 300 rats. Of the 60 adenomas found at histology, 25 percent were flat adenomas. Of the 298 adenocarcinomas, 12.7 percent had originated in a flat adenoma. Of the 180 colonic neoplasias (adenomas or adenocarcinomas), 29.4 percent were flat neoplasias (flat adenomas or adenocarcinomas arising in a flat adenoma), and the remaining 70.6 percent were exophytic neoplasias (tubulo or villous adenomas or adenocarcinomas arising in exophytic adenomas). From the 298 colonic adenocarcinomas, 1 was a intramucosal adenocarcinoma, 87 were overt adenocarcinomas, and 90 were lymphoid-associated carcinomas; in those 298 adenocarcinomas, no preneoplastic lesion could be recorded. In 208 animals, biopsies were taken from macroscopically visible colonic lesions, and, in the remaining 70 animals, the entire colon was processed for histologic examination. Flat adenomas were found in 3.8 percent of the 208 biopsy specimens and in 10 percent of the 70 colectomy specimens. Further, of the 40 adenomas found in biopsy specimens, 20 percent were flat adenomas, and, of the 20 adenomas found in colectomy specimens, 35 percent were flat adenomas.

CONCLUSIONS

The study reported herein indicates the existence of a "flat adenoma-adenocarcinoma sequence" in the colonic mucosa of Sprague-Dawley rats. The flat lesions of the colon constituted approximately one-third of the total neoplastic lesions seen in the rat following injections of 1,2-dimethylhydrazine. More flat adenomas were detected at histologic examination of the entire colon than in biopsies obtained from the macroscopically visible colonic lesions. Consequently, flat adenomas may be overlooked by naked-eye examination.

Ear tumours induced by experimental carcinogenesis in the rat: excision prevents early death

1,2-dimethylhydrazine (DMH) is widely used to induce colorectal tumours in rodents. Some of the animals develop ear as well as colorectal tumours. Rats with large, ulcerated ear tumours are usually sacrificed before the completion of the experiment. In this experiment, fourty-six male Spraque-Dawley rats were injected with 1,2-dimethylhydrazine (21 mg/kg body weight) once a week for 27 weeks to study the histogenesis of colorectal carcinoma. Thirty-six developed ear tumours. Fourteen of the 36 tumours were larger than 2 cm in diameter. These developed between 20-26 weeks and were surgically excised 1-5 weeks later. Four rats died postoperatively. The surgical removal of large ear tumours permitted the completion of the large bowel experiment on schedule (i.e. 27 weeks) in 10 (28%) of the 36 rats with ear tumours.

Involvement of aberrant p53 expression and human papillomavirus in carcinoma of the head, neck and esophagus

Biopsies from 34 patients with cancer of the head, neck or esophagus, 2 laryngeal papillomas, and 2 normal tonsils were analysed for human papillomavirus (HPV), Epstein Barr virus (EBV) genomes and mutated or elevated levels of p53. In 4 biopsies p53 was also analysed by DNA sequencing. HPV type 31 was found in one laryngeal cancer with normal p53 and HPV type 16 in two tonsil cancers with aberrant p53 expression. EBV was detected by PCR in 11 biopsies, but in situ hybridisation and immunohistochemistry, did not confirm this finding. Aberrant p53 expression was observed in approximately half of the tumours. These results support the involvement of both aberrant p53 expression and HPV in the aetiology of squamous cell carcinoma of the head and neck.

Histogenesis of small colonic adenocarcinomas

It has been claimed that in order to identify the type of mucosal lesion which precedes colonic adenocarcinoma only those tumours measuring < or = 1 mm in diameter should be considered. The review of the English literature indicates that only 35 colorectal adenocarcinomas measuring < or = 1 cm in diameter have been so far reported. From the three cases of colonic adenocarcinoma measuring 8 mm or less in diameter presented here, one adenocarcinoma originated in a flat adenoma, the second in an exophytic tubular adenoma, and the third showed no adenomatous component. It would thus appear that colonic adenocarcinomas can originate not only from exophytic adenomas or from flat adenomas but also from apparently nonadenomatous flat mucosa.

DNA aneuploidy and histologic dysplasia in long-standing ulcerative colitis. A 10-year follow-up study

PURPOSE

This study was designed to assess the presence of DNA aneuploidy and mucosal dysplasia, respectively, in 63 patients with long-standing ulcerative colitis.

METHODS

The DNA content in colonic biopsies was investigated, using a flow cytometry method, and compared with conventional histology. Patients were subsequently followed each or every second year with colonoscopy and histology. A second flow cytometry examination to monitor the DNA pattern was performed after 10 years.

RESULTS

Initially, abnormal DNA pattern (i.e., aneuploidy) was found in 13/63 (21 percent) patients. The colonic mucosa was flat in 10, polypoid in 1, and tumor infiltrated in 2. Eight of the 10 aneuploid cases with a flat mucosa showed no signs of histologic dysplasia. In one of two cases with simultaneous aneuploidy and low-grade dysplasia, a carcinoma Dukes B was found at subsequent colectomy. On the other hand, dysplasia (one low grade and one high grade) without aneuploidy was found in two patients at the initial investigation. After 10 years, 13 had been colectomized, 11 had died (7 noncolitis related), and 3 were lost to follow-up. In the remaining 36 living patients with intact colorectum, no case of histologic dysplasia, but 6 cases of DNA aneuploidy were discovered at the initial investigation. Of the six aneuploid cases, one was later reclassified as diploid and one consisted of an aneuploid adenomatous polyp (removed by polypectomy). At follow-up 10 years later, 3/4 of the other aneuploid cases showed repeated abnormal DNA pattern, now together with histologic low-grade dysplasia (in flat colon mucosa). The 30 patients with initially normal DNA patterns were all still diploid at re-examination 10 years later, but 2 now revealed low-grade dysplasia histologically.

CONCLUSIONS

DNA aneuploidy in chronic ulcerative colitis seems to be stable and it may precede histologic dysplasia by many years. It appears to be an additional marker for detecting neoplastic transformation in ulcerative colitis.

Herpes simplex viremia: report of eight pediatric cases and review of the literature

Bloodstream infection due to herpes simplex virus (HSV) is rare in the immunocompetent host but may be important in the pathogenesis of disseminated HSV infection in the immunocompromised patient. Using a simple blood-culture method, we detected herpes simplex viremia in eight immunologically compromised or immature children: two neonates, two oncology patients, and four transplant recipients. Only two patients initially exhibited evidence of mucocutaneous HSV infection. Blood was cultured for HSV because of perinatal exposure, for routine surveillance, or for the evaluation of fever, esophagitis, or oral lesions in immunocompromised patients. In five cases HSV was recovered only from the blood; in two other instances blood cultures for HSV were the first positive cultures. The time required for the detection of HSV by blood culture ranged from 1 day to 12 days. In one case viremia was transient and cleared without specific therapy. The other seven cases were treated with intravenous acyclovir; in four of these cases, therapy was initiated because of the positive blood culture. The detection of HSV in blood may promote early initiation of antiviral therapy and thereby improve prognosis.

Late seroconversion and high chronicity rate of hepatitis C virus infection in patients with hematologic disorders

BACKGROUND

Patients with hematologic disorders requiring repeated blood and platelet transfusions are at high risk for development of post-transfusion non-A, non-B hepatitis.

PATIENTS AND METHODS

Fifty-five patients with hematologic diseases and post-transfusion non-A, non-B hepatitis were studied. Sera were assayed for hepatitis C virus (HCV) antibodies with a second-generation enzyme-linked immunoassay. Sera from 40 patients were examined for the presence of HCV RNA with a nested PCR method.

RESULTS

The clinical picture of acute non-A, non-B hepatitis did not differ from that described in other patient groups: however, progression to chronic hepatitis was very common (95%). Thirty-eight (95%) of 40 patients, whose sera were analysed both serologically and for the presence of HCV RNA had verified HCV infections. In some patients time to seroconversion was prolonged, up to more than 14 months. Seventeen patients with resistant or relapsed acute leukemia were treated with combination chemotherapy during the acute or chronic phase of hepatitis. Suppression of the inflammatory activity as reflected by a decrease of serum aminotransferase levels was recorded during the subsequent pancytopenic period.

CONCLUSIONS

Hepatitis C has a high chronicity rate in patients with hematologic disorders which parallels the situation of hepatitis B in the immunocompromised host. Furthermore, like the situation in hepatitis B, the hosts' immune response to infection seems to be involved in the pathogenesis of liver injury. Time to seroconversion may be prolonged and detection of HCV RNA is therefore important for diagnosis.

Further studies on the carcinogenic-free interval following exposure in experimental esophageal tumorigenesis

247 C57B1 male mice were killed after Diethylnitrosamine (DEN) treatment at various time intervals ranging from one day to nine months. The number of esophageal tumors was divided by the length of the resected esophagus (i.e. Tumor Index = TI). Animals treated for up to 2 months had a TI of 0.1. Since the histological examination of the esophagi in those animals revealed only normal histology, the conclusion drawn was that the TI of 0.1 was a methodological error in assessing esophageal tumors by transillumination. Three months' treatment with DEN resulted in a 9-fold increased TI and 6 months' treatment in a 69-fold increased TI. Other groups of animals treated with DEN for the same period of time were allowed to survive 7, 9 or 12 months without further treatment. Animals treated with DEN for 1 day but followed without further treatment for 7 months demonstrated a 3.5-fold increased TI. For animals treated with DEN for only 14 days, (TI 0.1) and followed for 7 months with a carcinogenic-free diet, a 7-fold TI was observed. For the group of animals treated for 3 months (TI 0.9) but allowed to survive to complete 7 months on a carcinogen-free diet, a 5-fold higher TI was recorded. DEN animals treated for 6 months (TI 6.9) but allowed to survive 3 additional months had a TI of 9.6. A similar TI, namely 9.7, was found when the carcinogen-free interval was prolonged for 6 more months. These results suggest that clones of esophageal cells are "programmed" for tumor growth at an early stage of DEN treatment.(ABSTRACT TRUNCATED AT 250 WORDS)

Helicobacter pylori in 205 consecutive endoscopy patients

The presence of Helicobacter pylori in the gastric, antral mucosa of 205 consecutive, unselected gastroscopy patients was investigated by 1-3 biopsies for urea broth test and culture, 1 biopsy for histological examination and 1 blood sample for serology by ELISA. Overall, 41% were positive for H. pylori by culture, 32% by urea broth test, 24% by histological staining and 67%, 56% and 49% for the 3 cut-off limits applied to serology. Culture and serology indicated the presence of H. pylori in 79-92% of the 14 cases with duodenal ulcer, in 59-82% of the 28 cases with gastric ulcers, in 45-71% of the 51 cases with endoscopic gastritis and in 33-69% of 13 cases with oesophagitis. In patients with histological antritis, H. pylori was identified by culture in 71% (60/84), by serology in 95%, 88% and 81% with the different cut-off limits. The sensitivity of serology ranged from 99-78% depending on the cut-off limits and the specificity from 78-100% against all parameters combined. These results suggest that serology is a useful screening method for the presence of H. pylori. Future antibiotic treatment studies are required to evaluate the clinical relevance of H. pylori in gastrointestinal disease and to investigate the possibility to monitor eradication by serology.

Colectomy-proctomucosectomy with S-pouch: operative procedures, complications, and functional outcome in 69 consecutive patients

Sixty-nine patients were operated upon in a three-stage procedure. Early complications occurred in 29 percent after colectomy-ileostomy, in 25 percent after proctomucosectomy with ileoanal anastomosis and loop ileostomy, and in 9 percent after closure of loop ileostomy. Only three of these were considered serious. Seventy-one percent of the patients were readmitted into the hospital between the three operations or after the last one. Total hospital stay was 49 days (median); the range was 20 to 345 days. Reconstruction of the reservoir was performed in four patients owing to defecation problems, with satisfying functional results in two patients, while two emptied by catheter. There was no postoperative mortality or pelvic sepsis, and no pouches were excised. Ileostomy was re-established in two patients. At histopathologic re-evaluation of colectomy specimens, the diagnosis was changed from ulcerative colitis to Crohn's disease in three patients and to indeterminate colitis in five. Median follow-up was 4.3 years. Continent anal defecation without ileostomy was achieved in 67 patients (97 percent), with 4.1 bowel movements per day and 0.6 per night. Perfect continence was achieved in 55 percent in the daytime and in 43 percent at night. The low rate of reservoir-threatening complications is attributed to the three-stage procedure and the technical details in the surgical procedures.

A possible error in the interpretation of gastric carcinoma

Isolated clusters of pyloric cells having homogeneous, eosinophilic (i.e., "glassy") cytoplasm were present in 6 (18.2%) of 33 consecutive gastrectomy specimens. Clusters with "glassy" cells displayed either a glandular arrangement or appeared as cohesive clusters. Cohesive clusters could be misinterpreted as signet-ring cell adenocarcinoma. However, remnants of the apical mucous secretion from the "ordinary" pyloric cells, the nuclei usually near the free border of the cells, as well as the negative reaction in the "glassy" cytoplasm for neutral and acid mucins, helped to differentiate them from signet-ring adenocarcinoma cells.

Ischemic colitis of the cecum after renal transplantation masquerading as malignant disease

Fourteen years after kidney transplantation and following protracted rejection of the transplant, a patient developed abdominal pain, fever, and leukocytosis. Ultrasound demonstrated a pericolic abscess, and barium enema a deformity of the ascending colon suggesting malignant growth. Colonoscopy showed ulcerative and necrotic lesions of the cecum, and colonic carcinoma was suspected. At surgery, a granulomatous inflammatory reaction with fibrosis involving the kidney transplant and cecum was found. Histological examination revealed ulcerations secondary to ischemic colitis, but no malignancy. Thus, ischemic colitis should be ruled out in cases with a presumptive diagnosis of colonic malignancy at x-ray or endoscopy.

[Cardiovascular risk factors in the working population of Alicante]

The aim of the present study was to evaluate the prevalence of certain cardiovascular risk factors in the population of Asepeyo-Elche. The study sample was a working population of 697 persons (71.8% males and 28.2% females) with ages ranging from 15 to 65 years (mean age 34.7 +/- 13.2 years), seen during the first 6 months of 1990 in the health care center of Asepeyo-Elche. The evaluated cardiovascular risk factors and their prevalence rates were: hypertension (14.2%), hypercholesterolemia (18.5%), smoking (52.5%), hyperglycemia (3.5%), obesity (28.2%) and sedentariness (80.3%). We conclude that in our working population the prevalence rates of some cardiovascular risk factors are high and that intervention programs to modify the diet and lifestyle are mandatory to prevent the pathogenetic consequences of these factors.