Hemorrhagic shock and encephalopathy-like syndrome: report of a case with emphasis on the pathological findings

The case of a 5-month-old boy with sudden onset of shock, encephalopathy, watery diarrhea, bleeding tendency, and impaired hepatic and renal functions was reported. The different pathological findings as compared with the previous reports made the term "hemorrhagic shock encephalopathy-like syndrome" (HSE-like syndrome) more suitable for this case. Marked fatty metamorphosis with hemorrhage was found with a light microscope. Electron microscopy revealed flocculent densities in the mitochondria which might be a poor prognostic indicator in this syndrome. Diffuse electron-dense deposits in the peroxisomes were also seen and the significance of this finding was discussed. The patient died on the third day after admission due to multiorgan failures in spite of our aggressive management.

[Clinical types of adrenoleukodystrophy]

With gas chromatography, we established a method of determining plasma very long-chain fatty acids (VLCFA). Eight cases with adrenoleukodystrophy (ALD) were confirmed by using plasma VLCFA assay as the diagnostic method. The phenotypes of the 8 patients are as follows: 1. Childhood ALD; 2. Adolescent ALD; 3. Adult cerebral ALD: 4. Adrenomyeloneuropathy; 5. Addison's disease without neurologic involvement; 6. Asymptomatic ALD. We do not agree with Moser's classification of ALD as presymptomatic and asymptomatic, but would suggest to have a subclinical type of ALD.

Measuring lidocaine metabolite--monoethylglycinexylidide as a quantitative index of hepatic function in adults with chronic hepatitis and cirrhosis

Lidocaine is metabolized to form monoethylglycinexylidide (MEGX) via oxidative N-deethylation in the liver. To assess the clinical value of this lidocaine metabolite as a quantitative liver function test, we measured the serum MEGX concentration 15 min after intravenous administration of a single dose of lidocaine (1 mg/kg) in 24 adults with chronic hepatitis, 47 patients with cirrhosis and 26 normal controls. A fluorescence polarization immunoassay was used to obtain the MEGX value. The MEGX concentration in controls was 67 (54-95) ng/ml (median with 16th-84th percentile in parentheses), which was higher than 43 (23-61) ng/ml in patients with chronic hepatitis and 24 (7-52) ng/ml in those with cirrhosis (P < 0.05). In addition, the serum MEGX levels are proportional to the galactose elimination capacity, and inversely proportional to Pugh's score, the prothrombin time and indocyanine green retention ratio. If a MEGX concentration of below 54 ng/ml is taken as an indicator of hepatic dysfunction, its diagnostic sensitivity for hepatic disorder is 84.5%, specificity 88.5% and accuracy 85.6%. Furthermore, after a 10-month follow-up, patients with MEGX formation above 30 ng/ml had a higher survival rate than those with a MEGX concentration below this level (P = 0.004). In conclusion, the MEGX formation test reflects the severity of hepatic dysfunction quite well, making it valuable both in the quantitative evaluation of liver function and in the prognostic prediction of adults with liver diseases.

Hepatitis D virus infection among prostitutes in Taiwan

Two hundred and sixty-three adult licensed, 233 adult and 157 teenage unlicensed prostitutes from Taiwan were studied for prevalence and risk factors of hepatitis D virus (HDV) infection. The hepatitis B carrier rate among the three groups was 21, 15 and 20%, respectively, not significantly different from that of the general population in this area. However, the prevalence of HDV infection among carrier prostitutes was 55, 36 and 16%, respectively, much higher than that in general hepatitis B carriers. Univariate analysis revealed that the history of conducting paid sex for more than 12 months (P < 0.03), ear-piercing (P < 0.02), tattooing (P < 0.02), and gonorrhoea or syphilis (P < 0.005) were significant factors associated with HDV infection among these subjects. Multivariate analysis revealed that the history of ear-piercing and venereal diseases (P < 0.001) were still significant. In summary, genital ulcers caused by venereal diseases due to frequent sexual contact with multiple partners, and use of unsterilized needles in ear-piercing or tattooing play important roles in the high prevalence of HDV infection in prostitutes.

Hyperglycemia induced by chemotherapeutic agents used in acute lymphoblastic leukemia: report of three cases

Hyperglycemia may occur as a complication in patients with leukemia during induction therapy with L-asparaginase and steroids. The reported incidence is about 10%. The present report concerns three patients with acute lymphoblastic leukemia (ALL), complicated by hyperglycemia. Their ages were 10, 12, and 9 years, respectively. Past histories were normal, with no diabetes mellitus or other endocrine disorders in their families. Case 1 was an obese boy who developed pancreatitis and diabetic ketoacidosis (DKA) in his remission induction therapy which had included both L-asparaginase and steroids. Cases 2 and 3 both presented with polyuria and elevated postprandial blood sugar. For all patients, insulin was administered to control their blood sugars; the maximal daily dosage of insulin dispensed was 2.1 U/kg, 0.5 U/kg, and 0.7 U/kg, respectively. Increased plasma insulin and C-peptide levels suggestive of insulin resistance were observed in Case 3. The outcome of hyperglycemia in these three patients was good. The symptoms of this complication may vary from mild glucose intolerance to severe, or even fatal, DKA. Thus, periodic determinations of urine glucose and postprandial blood sugar are important for early recognition to prevent further life-threatening consequences.

Neural wave representation in early vision

The neural wave representation which describes spatiotemporal information in early vision is proposed in terms of extended Gabor functions in this paper. Its reasonability, completeness and uncertainty in spatiotemporal domains and their frequency domains were investigated. The ranges of these parameters in this representation were estimated on electrophysiological and psychophysical data. We derived the partial differential equations which the neural wave satisfied. The general significance of 3D neural wave representation has been explored.

Clinical studies of Henoch-Schönlein purpura in Chinese children

Over a 9-year period from 1983 to 1992, 50 patients with Henoch-Schönlein purpura were admitted to the Department of Pediatrics, Taichung Veterans General Hospital. There were 33 boys and 17 girls, with a male to female ratio of 2:1. Their ages ranged from 2 to 14 years with a mean of 6.3 years. Seventy percent of the patients were over the age of five. The months of peak incidence were October to December (48%). Fifty-four percent of the patients had evidence of preceding infections. The main clinical features were skin rashes (100%) followed by gastrointestinal symptoms (66%), joint symptoms (58%), soft tissue edema (30%) and renal involvement (30%). Hemograms showed leukocytosis, thrombocytosis, and elevated erythrocyte sedimentation rate in about half of these patients. Serological examinations were nonspecific; anti-streptolysin O titers were elevated in 40% of the patients. Forty-two percent of our patients had elevated serum IgA levels which bore no relationship to the symptomatology and duration of the illness. One patient had a complication of intussusception requiring surgical reduction. Another patient who had renal involvement progressed to end-stage renal disease. Eighty-two percent of our patients received prednisolone therapy at a dose of 1-2 mg/kg/day, with good response. Seventy-two percent of the patients recovered completely within one month after the onset of the malady. The overall prognosis remains good.

Congenital syphilis: report of twelve cases

Between 1983 and 1992 at the Taichung Veterans General Hospital, twelve congenital syphilis patients were diagnosed, according to the Centers for Disease Control (CDC) criteria. For the five boys and seven girls, ages at diagnosis ranged from 1 day to 8 months, with an average of 23 days. Among these 12 patients, four (33%) were premature. Seven patients (58%) were diagnosed in the past three years. These 12 patients were divided into inborn and outborn patient groups. Serological tests for syphilis were done in all inborn patients, but none in the outborns. All five outborn patients were symptomatic. In comparison, only one of seven inborn infants showed clinical evidence of congenital syphilis. The mean age at diagnosis was obviously older in the outborn patient group (53 days vs. 1 day). Six of ten patients (60%) had cerebrospinal fluid (CSF) abnormalities, while four of nine (44%) showed radiological abnormalities of bones. The hematologic and biochemical abnormalities compatible with congenital syphilis were also described. Penicillin was the drug of choice in ten patients. Despite adequate treatment, one patient died of respiratory failure. There has been no evidence of any signs of late congenital syphilis in those patients who survive. Congenital syphilis, a serious but preventable disease, is best treated adequately and early for minimal sequelae.

Primary biliary cystic tumors of the liver

Five cases of primary cystic tumors of the intrahepatic bile duct are documented over a 5-yr period. Clinically, two cases had recurrent episodes and one had a first attack of jaundice, fever, and pain in the upper abdomen; one complained of abdominal fullness and one was asymptomatic. The appearance of the tumors were single, large, multilocular, and cystic. Important radiological findings included irregular thickness of the cystic wall, internal septation, and papillary projection. Marked biliary dilation was demonstrated in four of the patients. On the cholangiogram, amorphous filling defects were seen in the dilated extrahepatic bile ducts, and mucinous material could be removed from the ducts as well. Obstruction of the bile ducts by this mucinous bile was assumed to be the cause of cholangitis in three patients. Histological examination revealed three cases of cystadenoma and two cases of cystadenocarcinoma.

Choledochal cysts: a nine-year review

Hospital records of 24 Chinese infants and children (7 males and 17 females) with choledochal cysts were reviewed. The patients were aged 1 day to 17 years. Abdominal pain, palpable abdominal mass and jaundice, either alone or in combination, accounted for most of the initial presentations. Twenty-two patients were classified as type I with surgery, while the other two patients were type V without surgery. Ultrasonography is a rapid and accurate diagnostic method in the initial evaluation. Cyst excision with Roux-en-Y hepaticojejunostomy was the treatment of choice in this series. Chronic cholecystitis with or without inflammation of choledochal cyst was the most common pathological finding. Five patients underwent liver biopsies, showing four biliary cirrhosis and one portal fibrosis. So far, there is no evidence of malignancy in any patient.

Immunogenicity of inactivated hepatitis A vaccine in children

BACKGROUND

Inactivated hepatitis A vaccine is now becoming available in many countries.

METHODS

To evaluate the immunogenicity and safety of inactivated hepatitis A vaccine in healthy children, 99 susceptible schoolchildren from 4 to 15 years of age received 360 enzyme-linked immunosorbent assay units of the inactivated hepatitis A vaccine at months 0, 1, and 6.

RESULTS

Antibody to hepatitis A virus seroconversion (> or = 20 mIU/mL) was 97% (96/99) in vaccinees after the first dose and 100% after the second (99/99) and booster (96/96) doses. The geometric mean titers of antibody to hepatitis A virus were 167, 465, and 4133 mIU/mL after each dose of vaccine, respectively. There were no significant side effects during the vaccination. Levels of antibody to hepatitis A virus were also tested in 9 susceptible children at day 7 and months 1 and 4 after the intramuscular injection of 2 mL of immune serum globulin. All children had measurable titers of antibody to hepatitis A virus 1 week after receiving immune serum globulin by sensitive enzyme immunoassay, but measurable titers had disappeared 1-4 months later.

CONCLUSIONS

The inactivated hepatitis A vaccine is safe and immunogenic in healthy children.

Changes of sex hormone levels in patients with hepatitis B virus-related postnecrotic cirrhosis: relationship to the severity of portal hypertension

The effect of portal hypertension on plasma sex steroid levels was studied in 49 patients with hepatitis B virus-related postnecrotic cirrhosis. In accordance with the Child-Pugh classification, 18 patients were classified as grade A, 15 grade B and 16 grade C. At the same time, 25 males who were admitted for physical check-up served as normal controls. Serum testosterone levels decreased (3.31 +/- 2.03 vs. 5.65 +/- 0.13 ng/ml) and estrone levels increased (0.16 +/- 0.08 vs. 0.09 +/- 0.02 ng/ml) significantly in patients with cirrhosis compared to the levels obtained in the controls. Moreover, these changes were associated with an increased severity of cirrhosis (P < 0.05 when severity increased from grade A to C). Hemodynamic values regarding hepatic venous pressure gradient and cardiac output demonstrated significant differences in patients from grade A to C, but the correlation between these two parameters was poor (r = 0.3242). The hepatic venous pressure gradient, the only direct measurement of portal hypertension, did not correlate with any of the measured hormone levels in patients with cirrhosis. There was, however, a highly significant negative correlation between cardiac output and testosterone levels (r = -0.8754, P < 0.01) and a positive correlation between cardiac output and estrone levels (r = 0.7522, P < 0.05) in grade C patients. On the basis of these results, we concluded that gonadal dysfunction is a common finding in patients with hepatitis B related postnecrotic cirrhosis, especially in those with decompensated liver function. The relationship between cardiac output and severity of liver disease suggests that the degree of portosystemic shunting probably increases as liver disease worsens.(ABSTRACT TRUNCATED AT 250 WORDS)

Replication of hepatitis delta virus RNA: effect of mutations of the autocatalytic cleavage sites

Hepatitis delta virus (HDV) contains a circular RNA genome of 1.7 kb. HDV RNA replication is thought to proceed via a rolling-circle mechanism that is dependent on autocatalytic cleavage and ligation reactions. However, it has never been established that these ribozyme activities are indeed involved in HDV RNA replication. To investigate the possible biological significance of HDV RNA self-cleavage, we constructed several HDV dimer cDNAs containing single-base substitutions of the 3' nucleotide of the genomic and the antigenomic self-cleavage sites. These mutations were known to affect self-cleavage in vitro to various extents. The effects of these mutations on HDV RNA replication were examined in hepatic and nonhepatic cell lines. The results showed that all of the mutants which had lost the in vitro self-cleavage activity could not replicate. The only mutant which retained full cleavage activity replicated as efficiently as the wild-type RNA. Thus, this study established that self-cleavage activity is required for HDV RNA replication in cells. Interestingly, the level of HDV RNA detected in cells transfected with this replication-competent mutant and that detected in cells transfected with the wild-type construct were similar in COS-7 cells but vastly different in HepG2 and Huh-7 cells, suggesting that HDV RNA self-cleavage activity may be modulated by cell-specific factors. We also compared the effects of mutations when the primary transcripts of these constructs were of either genomic or antigenomic sense. In constructs which synthesize primary transcripts of genomic sense, all of the antigenomic self-cleavage mutants produced as much hepatitis delta antigen (HDAg) as did the wild-type construct, even in the absence of detectable HDV RNA replication, whereas the genomic self-cleavage mutants produced very little HDAg. These and other data suggest that (i) the primary HDV RNA transcripts of both genomic and antigenomic polarities must first be processed to serve as a template for HDV RNA transcription, (ii) efficient cleavage at the antigenomic self-cleavage site is not required for HDAg expression, and (iii) HDV RNA replication most likely occurs by a double-rolling-circle mechanism.

[Motor function of the esophagus in patients with esophageal or gastric cancer]

Esophageal carcinoma is one of the most common malignant diseases in China. In order to clarify the pathophysiology of the esophageal motor dysfunction in the disease, a comparative study was done with esophageal manometry and 24 hour pH monitoring in 90 patients with esophageal carcinoma (EC) including 17 cardiac carcinoma (CC) and 56 healthy adult volunteers. The results showed that the resting pressure of the esophagus in patients was lower, particularly during swallowing and Valsalva test, than that of the normal subjects. It indicated that the patients with EC and CC had a hypodynamic esophagus so that a series of abnormal esophageal peristalsis and contractive waves were found. Besides the effect of mechanical obstruction of the tumor itself, it was believed to be a causative factor, at least in part, for the production of the clinical symptoms such as dysphagia and spastic odynophagia occurred during swallowing. Being the lower LESP, the patients with EC and CC presented pathological gastroesophageal reflux which was proved by 24 hour pH monitoring findings.

[Immunodiagnosis of tuberculous meningitis]

The detection of special anti-mycobacterial antibodies in cerebrospinal fluid (CSF) were evaluated. Among all the common coated antigens, it was found that PPD was the most potential one. Seven detecting methods were compared. It is shown that the classic ELISA technique is worth recommending. The results of the experiments, revealed that absorbance method was better than titration method, IgG antibody was more sensitive than IgM antibody and the sensitivity rate of IgM was not related with the course of the disease. The factors which influenced the levels of IgG antibody to mycobacterial antigens include focal signs and abnormal CT findings. False positive results were found in detecting anti-mycobacterial antibodies in a few cases. Immunodiagnosis was an useful method in diagnosing tuberculous meningitis and this study has provided ample theoretical basis for popularizing this technique.

Production and immobilization of D-aminoacylase of Alcaligenes faecalis DA1 for optical resolution of N-acyl-DL-amino acids

The production of D-aminoacylase by Alcaligenes faecalis DA1 was induced 5- to 50-fold by N-acetyl-D-amino acids. This strain produced about 443 units of D-aminoacylase and 52 units of L-aminoacylase per gram of cells (wet weight) when cultivated in a medium containing 1% N-acetyl-DL-leucine as the carbon source. The D-aminoacylase was partially purified by Fractogel DEAE 650 column chromatography and then immobilized on another Fractogel DEAE 650 column. The catalytic activity of the immobilized D-aminoacylase was 2,650 units per milliliter of gel. The Km values for the free and the immobilized enzymes were found to be 1.00 and 0.22 mM, respectively, using N-acetyl-D-methionine as a substrate. The optimal reaction pH and temperature for both soluble and immobilized enzyme were around 8.0 and 45 degrees C, respectively. The free enzyme was stable in the pH range from 5.0 to 11.0, whereas the immobilized enzyme tended to detach from the gel at pH values higher than 9.0. Both forms of enzyme were stable up to 40 degrees C. When used for the optical resolution of N-acetyl-DL-methionine, the immobilized enzyme maintained 90% initial activity after 17 days of continuous operation at 45 degrees C. The process of purification and immobilization of D-aminoacylase described in this report is very effective and easy to scale up.

[Clinical study of yi shen ning for treatment of kidney-yang deficiency after hormone withdrawal of primary nephrotic syndrome--clinical analysis of 100 cases]

This paper reports that Yi Shen Ning (YSN) which acts as warming and tonifying Kidney-Yang was administrated on 100 cases of primary nephrotic syndrome (PNS) while adrenocortical hormone (ACTH) was diminished to half dosage. The results showed that to apply the integrated TCM and WM according to the different stage of PNS was quite effective to treat deficient syndrome of Kidney-Yang appeared after withdrawal of ACTH. This recipe not only could improve the symptoms, but also pick plasma cortisol up earlier than expected, which was inhibited by exogenous hormone. The total remission rate of YSN group was 68.75%, higher than that of ACTH group (P < 0.05), especially for the cases dependent on exogenous hormone, the re-acquired remission rate reached to 58.3%.

Prevalence of anti-HCV among Chinese patients with acute and chronic liver disease

To assess whether the hepatitis C virus plays an important role in Chinese patients with acute and chronic liver disease, antibodies to HCV (anti-HCV) were measured by enzyme immunoassay in 67 patients with type A and B acute viral hepatitis, 165 patients with non-A, non-B (NANB) hepatitis, 438 patients with chronic hepatitis, 200 patients with postnecrotic liver cirrhosis, 72 patients with alcoholic liver disease, 55 patients with non-alcoholic fatty liver, 24 patients with toxic and drug-induced hepatitis, and 20 patients with other chronic liver diseases. Anti-HCV was not detected in sera from patients with type A and B acute viral hepatitis, toxic and drug-induced hepatitis, primary biliary cirrhosis, Wilson's disease, or lupoid hepatitis. The anti-HCV prevalence was found to be highest in patients with NANB hepatitis (59% in sporadic and 73.2% in transfusion-associated), 16.4% in non-alcoholic fatty liver, 5.6% in alcoholic liver disease, 6.8% in chronic hepatitis, and 16% in postnecrotic liver cirrhosis. In patients with chronic hepatitis, the anti-HCV prevalence was significantly higher in HBsAg-negative (15/34, 44.1%) than in HBsAg-positive cases (15/404, 3.7%; P less than 0.0001). The results indicate that HCV is a major agent of NANB hepatitis and plays an important role in HBsAg-negative chronic liver disease in Taiwan.