Immunoscintigraphy of inflammatory processes with a technetium-99m-labeled monoclonal antigranulocyte antibody (MAb BW 250/183)

Antigranulocyte immunoscintigraphy with a technetium-99m- (99mTc) labeled monoclonal antigranulocyte antibody (MAb BW 250/183) was performed in 34 in-patients of the departments of accident surgery and internal medicine in order to prove or exclude inflammatory processes. After labeling with 99mTc, 555 MBq, 99mTc-MAb (0.5 mg antibody) were slowly injected intravenously over a period of 5 min. A whole-body scan was done 4-6 hr postinjection, and planar or SPECT images were performed 6, 18, and 24 hr postinjection. Leukocyte immunoscintigraphy proved inflammatory suppurating processes in 20 cases (true-positive) and excluded them in 11 cases (true-negative). The findings were false-positive in two patients (hematoma without signs of infection, pseudoarthrosis) and false-negative in one patient (encapsulated lung abscess with pleural fibrosis). Anti-idiotypic human anti-mouse antibodies (HAMA) were found only in one out of 20 patients. According to our experiences, immunoscintigraphy with 99mTc-MAb BW 250/183 has a sensitivity of 95%, and is, therefore, well suited for the identification of leukocytic inflammations.

The effect of D- versus L-propranolol in the treatment of hyperthyroidism

The purpose of this study is to determine whether there is a difference in treatment of hyperthyroidism using either the D- or L-isomer of propranolol. Two groups of 20 patients with overt hyperthyroidism received either 120 mg L- or D-propranolol each for a period of 5 days. In the D-propranolol administered group there was a significant decrease in TT3 and fT3 plasma levels and in the ratio of TT3 to TT4; however, a significant increase occurred in rT3 values up to day 5. On the other hand, L-propranolol treatment resulted in a less pronounced decrease in TT4 and TT3 values, while all other thyroid hormone levels remained unchanged as, above all, did the T3/T4 ratio. The well known effect of D,L-propranolol upon peripheral conversion of T4 to T3 is thus not due to the beta-blocking action of L-propranolol but is mainly conditioned by the D-isomer which has no beta-blocking action itself.

Lipoma of the liver: computed tomographic, ultrasonographic, and cytologic findings

A hepatic lesion, manifest for several years in a 59-year-old female patient, was diagnosed as lipoma in the pre-contrast scan because of its attenuation value (-87 Hounsfield units (HU)); in addition, diagnosis was confirmed by aspiration cytology. In this case report the great merit of transmission computed tomography (TCT) is demonstrated, and ultrasound patterns and possible histogenetic origin of this neoplasm are discussed. The lipomatous liver tumors described in the literature with attenuation values of less than -60 HU are merely mixed tumors with lipomatous amounts of various sizes, whereas in true lipomas attenuation values from -80 to -120 HU have been measured.

[Erythrocyte elongation with 10% dextran 40,000: comparison of 2 substances]

A dosage-effect-study with two 10% dextrans 40,000 was carried out in 12 venous blood samples of healthy men aged from 21 to 45 years. Dextran A (trade name: Dextran 40,000 "Ebewe") and Dextran B (trade name: "Rheomacrodex") were added in dosages of 0.5 to 10 mg/ml whole blood and the elongation-index of erythrocytes at shearrate 50/sec was determined. From 1 mg up to 10 mg/ml the elongation-index in Dextran B showed a stronger decrease than in Dextran A. Under the highest dosage the difference was about 20%. So it was possible to show that in spite of identical molecular weight there are different effects on deformability of erythrocytes. This should be taken into account for parenteral treatment.

Transient prealbumin-associated hyperthyroxinemia in TSH-producing pituitary adenoma

This case report describes a 38-year-old male who was hospitalized for further clarification of clinically mild hyperthyroidism. His increased total hormone levels, the elevated free thyroid hormones and the elevated basal TSH with blunted response to TRH strongly suggested a pituitary adenoma with inappropriate TSH incretion. Transmission computed tomography showed an intrasellar expansion, 16 mm in diameter. The neoplastic TSH production was confirmed by an elevated alpha-subunit and a raised molar alpha-sub/TSH ratio. However, T4 distribution on prealbumin (PA, TTR), albumin (A) and thyroxine binding globulin (TBG) showed a clearly increased binding to PA (39%), indicating additional prealbumin-associated hyperthyroxinemia. The absolute values of PA, A and TBG were within the normal range. After removal of the TSH-producing adenoma, basal TSH, the free thyroid hormones and T4 binding to prealbumin returned to normal. Therefore, the prealbumin-associated hyperthyroxinemia had to be interpreted as a transitory phenomenon related to secondary hyperthyroidism (T4 shift from thyroxine binding globulin to prealbumin) rather than a genetically conditioned anomaly of protein binding.

Differentiation of Lymph-Node Metastases by Anti-CEA Immunoscintigraphy in a Patient with Follicular Thyroid and Breast Cancer

Supraclavicular lymph node metastases appeared in a female patient six years after thyroidectomy, radioiodine therapy and external radiation for a follicular thyroid carcinoma and four years after mastectomy and lymphadenectomy for an invasive ductal breast cancer. It was not possible either by conventional imaging methods or by serological methods, to assign the metastases to one of the two primary tumors. Anti-CEA immunoscintigraphy and SPECT of the cervicothoracic region showed a circumscribed pathological uptake of 99mTc-labeled anti-CEA antibodies in the area of the supraclavicular lymph nodes. The preoperative suspicion of lymph-node infiltration by CEA-expressing breast cancer cells was confirmed histologically after surgical removal of the lymph nodes.

Embryonation and infectivity of Ascaris suum eggs. A comparison of eggs collected from worm uteri with eggs isolated from pig faeces

Ascaris suum eggs were collected from pig faeces or dissected from worms obtained from the same pigs. Eggs from the two sources were allowed to embryonate in 0.1 N H2SO4, in 1% buffered formalin or in tap water. The embryonation of the sulphuric acid and water cultures occurred at the same speed, while the formalin cultures developed slightly more slowly. By experimental inoculation of helminth-free pigs and subsequent counting of white spots in the livers and larvae in the lungs day 7 p.i., the infectivity of eggs dissected from worm uteri and embryonated in sulphuric acid (a normal laboratory procedure) was compared with that of eggs collected from faeces and embryonated in water (i.e. more naturally developed eggs). The results suggest that the two types of eggs were equally infective. For this reason the common practice of using Ascaris eggs dissected from worms for experimental infections might be acceptable.

Misinterpretation of iodine uptake in papillary thyroid carcinoma and primary lung adenocarcinoma

This is the first case report of an iodine-storing metastasising carcinoma of extrathyroidal origin and the simultaneous presence of a papillary thyroid carcinoma. In the course of the disease, an increase in pathological iodine uptake was observed after repeated iodine-131 ablation, so that the original tentative diagnosis of a metastasising, differentiated thyroid carcinoma appeared to be confirmed; moreover, the histological work-up of a femur metastasis--without adequate immunohistochemical assessment--was misinterpreted. What is also remarkable about this case report is a pathological iodine-131 uptake both in the extrathyroidal primary tumor and the metastases.

Transient Prealbumin- Associated Hyperthyroxinemia in TSH-Producing Pituitary Adenoma

This case report describes a 38-year-old male who was hospitalized for further clarification of clinically mild hyperthyroidism. His increased total hormone levels, the elevated free thyroid hormones and the elevated basal TSH with blunted response to TRH strongly suggested a pituitary adenoma with inappropriate TSH incretion. Transmission computed tomography showed an intrasellar expansion, 16 mm in diameter. The neoplastic TSH production was confirmed by an elevated alpha-subunit and a raised molar alpha-sub/ATSH ratio. However, T4 distribution on prealbumin (PA, TTR), albumin (A) and thyroxine binding globulin (TBG) showed a clearly increased binding to PA (39%), indicating additional prealbumin-associated hyperthyroxinemia. The absolute values of PA, A and TBG were within the normal range. After removal of the TSH-producing adenoma, basal TSH, the free thyroid hormones and T4 binding to prealbumin returned to normal. Therefore, the prealbumin-associated hyperthyroxinemia had to be interpreted as a transitory phenomenon related to secondary hyperthyroidism (T4 shift from thyroxine binding globulin to prealbumin) rather than a genetically conditioned anomaly of protein binding.

99mTc-labeled monoclonal anti-carcinoembryonic antigen antibody (BW 431/26). Clinical results in the detection of colorectal carcinomas and recurrences

With the introduction of 99mTc-labeled monoclonal antibodies against carcinoembryonic antigen (CEA) a clinically relevant extension can be expected in the diagnosis of colorectal tumors by immunoscintigraphy (IS). This study comprises a total of 49 patients (primary colorectal tumors, occult neoplasms, and suspicious recurrences), in whom IS with 99mTc monoclonal antibody (MAb) BW 431/26 was performed. After injection of 1100 MBq 99mTc MAb BW 431/26 a whole-body scan was performed in anterior and posterior projection 5 1/2 h later, and SPECT of the abdominal region was done after 6 and 24 h. In the course of primary tumor identification (n = 20) all coloscopically diagnosed and operatively verified carcinomas were confirmed and correctly localized by IS (n = 11). In three patients with positive IS and suspicious coloscopic findings surgery was refused by patients and relatives. In five cases IS was true negative and in 1 case false positive. In the diagnosis of recurrences (n = 29) IS showed an uptake in computer-tomographically and coloscopically suspicious areas in 17 cases. In 12 cases IS was rated negative (11 true-negative findings in scar and granulation tissue, 1 false-negative finding in para-aortal lymph nodes). Elevated serum CEA levels were found only in 17 of 31 patients with true-positive IS. In postoperative cancer care IS with 99mTc-labeled anti-CEA antibody plays a preeminent role in the exclusion or identification of colorectal recurrences.

3,5,3'-Triiodothyroacetic acid (TRIAC) effects on pituitary thyroid regulation and on peripheral tissue parameters

The effects of TRIAC on peripheral thyroid hormones, TSH incretion and peripheral tissue parameters were investigated in 13 mildly obese patients (group I) and 10 volunteers of normal body weight (group II). TRIAC was administered 3 x 1 mg daily over a period of 8 days to both groups. In group I (on a 400 kcal low caloric diet) bTSH and fT4 decreased significantly whereas TT4 decreased only insignificantly. TT3 and fT3 rose significantly due to the cross-reactivity of the employed antibody. The peripheral tissue parameters cholesterol, ankle jerk and systolic time interval did not reveal any changes suggesting an increase in metabolic rate. The increase in heart frequency was not significant either. The significant rise in sex-hormone binding globulin was most probably associated with the weight reduction of 3.1 +/- 1.2 kg per week. In group II (on normal diet) bTSH and fT4 decreased significantly whereas TT4 decreased only insignificantly. As in group I, TT3 and fT3 rose significantly. Also in group II TRIAC did not cause alterations in the peripheral tissue parameters. In contrast to the obese group the volunteers in group II showed no significant rise in sex-hormone binding globulin and no reduction of body weight. Side effects such as nervousness, tremor or palpitations were not observed. Thus, TRIAC does not induce an increase in peripheral metabolic rate, not even under a TSH-suppressive dose as high as 3 x 1 mg per day.

A new measuring design for autonomic dysfunction of skin in neuropathies: hyperthermal laser-Doppler flowmetry

Twenty patients suffering from diabetic neuropathy, 20 patients suffering from alcoholic neuropathy and 20 healthy volunteers within the same age range were studied for the stimulability of microcirculation with a new measuring design. A laser method (laser-Doppler flowmetry) was used to evaluate the increase of the microvascular blood flow of the skin during the hyperthermal phase. It evaluated the degree of increase of microcirculatory blood flow as well as the time from the beginning of hyperthermy to the onset of change in perfusion (the hyperthermal perfusion latency). This was significantly prolonged in both neuropathy groups; the increase of the microvascular blood flow in the diabetic neuropathies was significantly lower than found in alcoholic neuropathies and in healthy volunteers.

High mite-allergen exposure increases the risk of sensitization in atopic children and young adults

Concentrations of major allergens of Dermatophagoides pteronyssinus (Dpt) and D. farinae (Df), Der p I and Der f I, were determined in 183 dust samples of mattresses of 133 atopic and 50 nonatopic children by a sandwich-type ELISA. Atopic children and young adults living in houses with high levels of Der p I and Der f I (greater than or equal to 2000 ng/gm of dust) were found to have significantly higher serum IgE levels to Dpt and Df (p less than 0.0001) compared to patients with low mite-allergen exposure. Washed leukocytes of 55 atopic children and 14 control subjects were investigated for in vitro histamine release to serial dilutions of Der p I; 86% of highly exposed (greater than or equal to 10,000 ng/gm) children demonstrated positive histamine release in response to Der p I compared to 17% in the group with very low exposure (less than 400 ng/gm). There was a positive correlation between basophil sensitivity (rs = 0.6; p less than 0.0001) and reactivity (rs = 0.54; p less than 0.0001) to Der p I and mite-allergen exposure. The relative risk for sensitization in the highly exposed group versus the group with very low exposure was sevenfold to 32-fold increased. We conclude that high concentrations of mite allergen (greater than or equal to 2000 ng/gm) increase the risk of specific sensitization in atopic children and young adults and thus may facilitate allergic airway disease.

Diagnosis of hepatic hemangioma with 99mTc-labeled red cells: single photon emission computed tomography (SPECT) versus planar imaging

This paper reports the results of a prospective study carried out to demonstrate the most important advantages of 99mTc-blood pool single emission computed tomography (SPECT) versus the established method of planar scintigraphy (PS) in the non-invasive diagnosis of liver hemangiomas. The study group comprised 40 patients in whom positive evidence of 56 hemangiomas, detected incidentally in the course of screening examinations, was established via SPECT and PS. The sensitivity of SPECT was 51/56 (91%), of PS 22/56 (39.3%); for lesions smaller than 30 mm in diameter, the sensitivity of SPECT was 31/38 (81.6%), of PS 6/38 (15.8%). All lesions with diameters of more than 30 mm were detected by both PS and SPECT. However, the SPECT method proved to be clearly superior in the identification of lesions which were smaller than 30 mm and located in unfavourable topographical sites (dorsal or subphrenic). The study proves that SPECT with 99mTc-labeled erythrocytes is the ideal complement to ultrasonography in the detection of liver hemangionas; its major advantage over TCT (transmission computed tomography) is its safe application in cases with contrast agent intolerance and hyperthyroid patients. Moreover, liver biopsies are dangerous and ill-suited for the verification of diagnosis.

[Tl-201 myocardial SPECT in silent myocardial ischemia and angiographically proven coronary heart disease]

Silent myocardial ischemia is defined as true myocardial ischemia without angina pectoris in patients with angiographically detected coronary artery disease. In this study 52 patients (46 male, 8 female: mean age 53 years) with a pathological exercise test but no symptoms were investigated. They showed stenosis of 75% or more of the diameter in at least one coronary segment on angiography. Prior to or after catheterization (within 14 days) Tl-201 SPECT was done and evaluated independently of angiography. A clear correlation between angiographically confirmed stenosis and reversible perfusion defects with Tl-201 SPECT was established (62 out of 76 lesions). Furthermore, there was a significant relation between angiographically detected subtotal or total occlusions of coronary vessels and irreversible perfusion defects using Tl-201 SPECT (35 in 44 lesions) (p less than 0.001). In patients with ST depression but without angina pectoris during the exercise test, the Tl-201 SPECT is highly suited to determine the hemodynamic effect of coronary stenoses.

[Myocardial damage following lightning injury]

In a 27-year-old woman, struck by lightning behind the left ear, the ECG showed signs of an acute posterior-lateral myocardial infarction after 1 h of unconsciousness and loss of memory. Her serum enzymes were increased as is typical of myocardial infarction, but the patient did not complain of cardiac symptoms. Besides clear signs of lightning injury, the patient showed a hemorrhage throughout the left breast and transient pericardial effusion was observed by echocardiography. In the course of two months, the ECG revealed a regression to unspecific ST-T-deviations and serum enzymes became normal. TI-201-myocardial-scintigraphy (SPECT), done six days and two months after lightning injury, excluded reversible and irreversible perfusion defects.

[Isolated thyroid gland sarcoidosis and hyperthyroidism]

A case of isolated sarcoidosis of the thyroid gland, associated with hyperthyroidism, is reported in a 28-year-old male patient whose thyroid was removed for hyperthyroid multinodular goitre. Histology revealed a regressive adenoma and sarcoidosis in non-adenomatous thyroid residue. Further diagnosis, therapeutic management and a 3-year follow-up did not disclose any specific changes or involvement of other tissues. Isolated thyroidal sarcoidosis with hyperthyroid alterations are extremely rare and mostly chance findings; simultaneous occurrence of thyroid sarcoidosis and hyperthyroidism may be a symptom of gland infiltration for which an adequate explanation is still lacking.

[Metastatic thyroid cancer: sudden death following aclarubicin therapy]

We report on a 62-year-old patient with a metastasising, only poorly differentiated follicular thyroid carcinoma, who was subjected postoperatively to chemotherapy with Aclarubicin. Aclarubicin (Aclaplastin) is a new cytostatic agent, from the group of anthracyclines, with fewer side effects and clearly diminished cardiotoxicity. The patient died suddenly after two treatment cycles with clinical symptoms of cardiac insufficiency; the post-mortem examination, however, revealed that two metastases in the myocardium might have been the cause of death; toxic myocardial damage could be excluded histologically. Upon occurrence of cardial symptoms and signs during therapy with cytostatic agents of thyroid carcinoma with Aclarubicin, whose cardiotoxic side effects are known, the possibility of metastatic spread in the myocardium should, nevertheless, also always be considered in the differential diagnosis.

[Microcirculation in parenteral Ginkgo biloba extract therapy]

15 patients with arteriosclerotic lesions in the extracranial brain arteries, randomly selected, were treated with an infusion of 250 ml physiological NaCl and 25 ml Ginkgo biloba extract (Tebonin). A second group (n = 15) received 250 ml NaCl without drugs stimulating blood flow. The skin microcirculation was measured in vivo by means of a helium-neon laser at one of the 4 extremities. Perfusion increased significantly (p less than or equal to 0.01) in response to Ginkgo biloba extract als composed with the response in the control group. The results justify the administration of Ginkgo biloba extract in vascular diseases.

Monoclonal antibodies to the major feline allergen Fel d I. I. Serologic and biologic activity of affinity-purified Fel d I and of Fel d I-depleted extract

Monoclonal antibodies were raised against a major feline allergen, Fel d I. The specificity of the antibodies for Fel d I was demonstrated by a modified crossed immunoelectrophoretic procedure. These antibodies were used in affinity purification and depletion. Fed d I was eluted from the affinity matrix at a low pH. It was tested in serologic and biologic assays. Results of both the RAST and the histamine release test with affinity-purified Fel d I confirmed that it is a very potent allergen for the majority of patients allergic to cats. In the extract depleted with the monoclonal antibody, the ratio Fel d I/cat albumin was reduced by a factor of 20. With this depleted extract, 18 of 25 patients showed a reduction greater than 50% of the bound anti-IgE in the RAST compared with the RAST with crude cat extract. In the histamine release test with cells from two patients, the activity of the depleted extract was reduced by factors of 30 and 40, respectively. Depletion of Fel d I by polyclonal antibodies resulted in a reduction of the ratio Fel d I/cat albumin by a factor of 330. In the RAST, a reduction of the IgE response greater than 50% was found in 23 of 25 patients; in 12 patients the reduction was greater than 90%. In the histamine release test, the polyclonally depleted extract was 200 to 300 times less potent than the crude cat-dander extract. These results indicate that a very large proportion of the allergenic activity of cat-dander extract is caused by a single molecule: Fel d I.