Ingested foreign body mimicking an appendicolith in a child

We describe an unusual case of a child who had ingested sand and stones and presented with signs and symptoms suggestive of appendicitis. Plain radiographs revealed calcific opacities in the right iliac fossa simulating appendicoliths. At surgery and histopathology a small sealed off perforation of the terminal ileum with hard concretions in the wall was observed.

Determination of Non-bilayer Phospholipid Arrangements and their Antibodies in Placentae and Sera of Patients with Hypertensive Disorders of Pregnancy

Studies suggest that preeclampsia (PE) originates in the placenta and is associated with deficient trophoblast invasion of spiral arteries. The direct cause remains unknown, but preeclampsia is often associated with circulating factors that can induce generalized endothelial dysfunction. Antiphospholipid antibodies (APA) in circulation are also associated with vascular diseases. Although the quantification of APA is not currently used as a prognostic of the risk of PE, studies suggest that thrombophilias play a role in PE pathogenesis. In fact, the pathology of placentae from PE and Antiphospholipid syndrome patients is similar; atherosis, thrombosis and infarction, and endothelium activation represent the pathological mechanisms. We identified a new antibody which recognizes non-bilayer phospholipid arrangements (NPA) in membrane models and in cell membranes in vivo, and which triggered an autoimmune-like disease in mice. We evaluated the presence of NPA in the placentae and in sera, and whether NPA induced NPA antibodies in patients with hypertensive disorders of pregnancy (HDP). Results showed increased levels of NPA in the syncytiotrophoblast, extravillous cytotrophoblast, syncytial knots and the amnion epithelial cell membranes of the placenta, as well as increases in NPA and NPA antibodies in sera from HDP patients, when compared with controls. This suggests that NPA derived from placenta could be one of multiple factors associated with pregnancy pathologies.

Oyster-associated outbreaks of Norovirus gastroenteritis in Singapore

Outbreaks of gastroenteritis associated with the consumption of raw imported half-shelled frozen oysters occurred in Singapore between 16 Dec 2003 and 04 Jan 2004. A total of 305 cases were reported with clinical symptoms of diarrhoea (94%), abdominal cramps (72%), vomiting (69%) and fever (54%). The median incubation period was 30.8h and the duration of illness was 2-3 days. The overall relative risk of oyster consumption was 14.1 (95% CI: 8.3-24.0, P<0.001). Stool and oyster samples tested negative for common bacterial pathogens, including Vibrio parahaemolyticus. However, stool samples were positive for the presence of Norovirus group II RNA via RT PCR while oyster samples indicated the presence of Norovirus particles by electron microscopy. The clinical and epidemiological features were suggestive of Norovirus gastroenteritis and were subsequently confirmed by laboratory tests of stools and implicated oysters. Steps have been taken to ensure that food outlets do not thaw frozen oysters and serve them raw.

Slide session, British Society for Haematology, 45th Annual Scientific Meeting, Manchester, 2005

Each year at the Annual Scientific Meeting of the British Society for Haematology, there is a slide session in which microscopic slides of six patients with haematological disorders are discussed by two experts. Further data and the final diagnosis are then provided. The slide session is presented here, as it occurred at the meeting.

Plasmodium chabaudi adami: use of the B-cell-deficient mouse to define possible mechanisms modulating parasitemia of chronic malaria

Our previous observation that B-cell-deficient JH-/- mice utilize T cell-dependent immunity to suppress acute Plasmodium chabaudi adami-induced malaria but then develop chronic low-level parasitemia prompted this study of control mechanisms for chronic parasitemia. When we infected JH-/- mice with blood-stage parasites, chronic parasitemia exacerbated after the 6th month and persisted for up to 17 months. This exacerbation of parasitemia could not be attributed to host aging because the time-course of acute infection in naïve aged mice was nearly identical to that seen in young mice. Nor could exacerbated parasitemia be attributed to mutation in the parasite genome resulting in increased virulence; when subinoculated into naïve JH-/- mice, parasites from chronically infected JH-/- mice with exacerbated parasitemia produced acute stage parasitemia profiles in most recipients comparable to those seen in JH-/- mice upon infection with the original stabilate material. Of the pro-inflammatory cytokines measured, including IFNgamma, TNFalpha, IL-12p70, and MCP-1beta, none were significantly different in the sera of mice with exacerbated parasitemia compared to uninfected controls. Levels of IL-6 were significantly (P=0.002) less in the sera of mice with exacerbated parasitemia. Serum levels of the anti-inflammatory cytokine, TGFbeta, were significantly depressed in chronically infected JH-/- mice compared to uninfected controls. In contrast, IL-10 levels were markedly increased. These findings suggest that the cytokine balance may be disturbed during chronic malaria, thereby impacting on mechanisms that modulate levels of parasitemia.

A uterine fibroid presenting as an incarcerated umbilical hernia during pregnancy

Uterine leiomyomas (fibroids) affect 2.6% of pregnancies. They are usually silent, but on occasions can complicate pregnancies. A case of a 30-year-old pregnant woman with a uterine fibroid incarcerated in an umbilical hernia is presented. This is the second reported case of a fibroid in pregnancy with such a presentation.

A prognostic model for prolonged event-free survival after autologous or allogeneic blood or marrow transplantation for relapsed and refractory Hodgkin's disease

There are several prognostic models for Hodgkin's disease (HD) patients, but none evaluating patient characteristics at time of blood and marrow transplantation (BMT). We developed a prognostic model for event-free survival (EFS) post-BMT based on HD patient characteristics measured at the time of autologous (auto) or allogeneic (allo) BMT. Between 1/1991 and 12/2001, 64 relapsed or refractory HD patients received an auto (n=46) or allo (n=18) BMT. A multivariate prognostic model was developed measuring time to relapse, progression or death. Median follow-up was 51.7 months; median EFS for auto and allo BMT was 36 and 3 months, respectively (P=0.001). Significant multivariate predictors of shorter EFS were chemotherapy-resistant disease, KPS <90 and > or =3 chemotherapy regimens pre-BMT. Patients with two to three adverse factors had significantly shorter EFS at 2 years (58 vs 11% in auto; 38 vs 0% in allo BMT patients). Despite a selection bias favoring auto BMT, the model was valid in both auto and allo BMT groups. We were able to differentiate patients at high vs low risk for adverse outcomes post-BMT. This prognostic model may prove useful in predicting patient outcomes and identifying high-risk patients for novel treatment strategies. Validation of this model in a larger cohort of patients is warranted.

Susceptibility to basal cell carcinoma: associations with PTCH polymorphisms

Loss of function of the human patched gene (PTCH) is common and critical in basal cell carcinoma (BCC) development. Indirect evidence suggests polymorphism in PTCH mediates BCC risk. We studied 659 BCC cases and 300 controls to determine if exon 2(318), 3(429), 11(1552), 12(1665), 12(1686), 14(2199) and 23(3944) and intron 9(1336-135) and 15(2560+9)PTCH variants were sufficiently common for use in case-control studies, and if selected markers were associated with risk. Intron 15(2560+9) and exon 23(3944) variants were studied further. Their genotype frequencies were not significantly different in controls and cases, though frequency of the G(2560+9)-C(3944) haplotype was lower in all cases (odds ratio=0.44, p=0.009) and those stratified by BCC site and rate of development of further tumours. This association was not mediated by the extent of UVR exposure. We confirmed the robustness of these findings by showing these associations demonstrated similar odds ratios in two groups of randomly selected cases and controls, and using the false positive report probability (FPRP) approach described by Wacholder et al. (2004). The FPRP value (0.168) was in the noteworthy category. These data, showing for the first time that PTCH polymorphism mediates susceptibility, are compatible with reports showing that PTCH haploinsufficiency influences development of BCC precursor lesions.

The value of a CT-guided fine needle aspirate in infants with lung abscess

OBJECTIVE

To describe the range of pathogens isolated from a lung abscess in infants less than one year of age. To assess the role of direct culture from the abscess.

METHODS

The two index cases were managed in 2002. An institution-based review was conducted of all infants up to one year of age diagnosed with a lung abscess between 1989 and 2002. Data sources were hospital's disease index and Neonatal Intensive Care Unit Audit database using ICD9 and ICD10 diagnostic codes for 'lung abscess'.

RESULTS

Five infants, under the age of one year, were treated for a lung abscess. In the one case where the abscess was left-sided it was associated with a congenital cystic adenomatoid malformation of the lung. Pathogens were isolated following direct culture of the abscess in four cases. In three cases a single pathogen was isolated: pseudomonas aeruginosa, staphylococcus aureus and haemophilus influenzae. In one case a mixture of escherichia coli, streptococcus milleri and an anaerobe, propionibacteria, were cultured. Antibiotic therapy was directed at the identified pathogen(s) in all four cases. There was no mortality or recurrence.

CONCLUSION

Predisposing factors for a lung abscess in infancy include prematurity, assisted ventilation, congenital lung anomaly and aspiration. Given the range of potential pathogens, direct culture by CT-guided fine needle aspiration is recommended to direct appropriate intravenous medical therapy provided the abscess is located peripherally.

A randomized trial of amifostine as a cytoprotectant for patients receiving myeloablative therapy for allogeneic hematopoietic stem cell transplantation

We initiated a randomized study of amifostine (the organic thiophosphate formerly known as WR-2721) given to patients during myeloablative conditioning therapy for allogeneic bone marrow transplantation. Amifostine was given at a dose of 1000 mg/day of conditioning and was well tolerated if attention was given to serum calcium levels, blood pressure and antiemetics. Since August 1998, 60 patients (30 on each arm) have completed the study. There was no significant difference in the days to neutrophil or platelet engraftment in either arm of the study. Significantly, the duration of grade I-IV mucositis was decreased in the group that received amifostine (P=0.02). Also grade III or IV infections (P=0.008), duration of antibiotic therapy (P=0.03) and duration of fever (P=0.04) were significantly reduced with amifostine. However, there were no differences in the incidence of grade III or IV mucositis, liver toxicity or renal toxicity. There were also no differences in early mortality, relapse and long-term survival. We conclude that amifostine, while reducing the duration of mucositis and infections (possibly through some preservation of gut mucosal integrity), has a modest effect in allogeneic bone marrow transplants given the multiplicity of factors influencing organ toxicity and survival in this setting.

Obesity as an independent predictor of posttransplant diabetes mellitus

BACKGROUND

In the general population, there is a clear association between obesity and type 2 diabetes mellitus. However, the evidence of relationship between body mass index (BMI: weight/height(2)) and the risk of posttransplant diabetes mellitus (PTDM) is inconsistent when studied at a level of single center. The aim of our study was to determine if pretransplant BMI is an independent risk factor for PTDM at our center and to demonstrate the pattern of weight gain in patients who develop PTDM.

METHODS

This is a retrospective analysis of renal allograft recipients at University of Colorado Hospital. The medical records of patients who received a kidney transplant from January 1998 to March 2001 were screened to identify the cases of PTDM. Controls were matched for immunosuppressive regimen, gender, and type of donor. A total of 18 cases and 36 controls were identified.

RESULTS

The incidence of PTDM in our transplant population was 10%. Of these cases, 72% developed PTDM in the first 2 months after transplant, and 38% of them required insulin. On multivariate analysis, BMI was significantly associated with PTDM (adjusted odds ratio 1.22, 95% confidence interval 1.04-1.42) while controlling for number of rejections, age, and other factors. We also noticed that weight gain was significantly lower in patients who developed PTDM after transplantation.

CONCLUSIONS

We conclude that obesity is an independent predictor of PTDM. The weight gain was significantly poor among patients who developed PTDM. Among all the risk factors for PTDM, obesity is the only modifiable risk factor before transplantation. Obese patients should be treated with a less diabetogenic immunosuppressive regimen and be counseled to lose weight before transplant.