[Nutrition and anaemias in critical illness]

INTRODUCTION

We made a clinical study, about nutrition in seriously ill patients, which includes a typical heterogeneous group of critical ill patients, with/without anaemia's, that have been admitted to Intensive Care Unit, ICU. It is difficult to individualize and to generalize the relative importance of all the factors that can contribute to these anaemia's in the admission to the Unit, including nutritional deficiencies, inflammatory alterations, the immune response to aggressions, inmunitary modifications and the complex relations existing between these clinic processes.

OBJECTIVE

Indirect valuation of the nutritional situation and anaemia's, in a typical heterogeneous group of critical ill patients.

METHOD/RESULTS

We studied 202 patients admitted to ICU, of varied and heterogeneous origin, classifying them in 3 groups: control, post surgery and septic group's, becoming the indirect valuation of the nutritional situation on the basis of: Global Subjective Valuation, (VGS) and the nutritional analytical determinations of total lymphocytes, albumin, and transferrin. Also we made hemogram and determinations of sideremia and ferritinemia to all of them. In 57% of the patients, we observed levels haemoglobin < 12.5 g/dl, basically in the post surgery groups, 68 patients and septic group's, 10 patients. And with levels haemoglobin < 10 g/dl, in 25 patient's (12.3%). There were 87 patients, 23 of them in the control group's, 58 in the post surgery and 5 septic group's, with levels haemoglobin > 12.5 g/dl. Regarding the nutritional prognoses indicators, (VGS + nutritional profile), in the control group's, they did not present anaemia nor analytical clinical under nourishment, in the post surgery group's, anaemia and slight under nourishment and in the septic group's, anaemia and moderate under nourishment. There were significant differences between the surgery and septic group and control group's, in values of haemoglobin, iron, total lymphocytes, transferrin and albumin. A statistical correlation between sideremia and albumin was significative. (Spearman's Rho 0,277).

CONCLUSIONS

The evaluation of the anaemia and nutritional valuation. and the ferroterapic treatment, as immune-nutrient, can be beneficial for the integrity of the immune system and its defense's abilities against the aggressions in critically ills.

Revision of the South American species of Neralsia (Hymenoptera: Figitidae) with the description of eight new species

Neralsia is a genus of Figitid hymenopterans present in both the Neartic and the Neotropical regions. In this work, material from several museums (including all types of the South American species of Neralsia) was analyzed with light and electron microscopy. The South American species are studied as a whole, reviewing 26 previously cited species and describing eight new species. A key for their identification is included and the characters to differentiate species here considered are illustrated.

[Genotypic analysis in primary cutaneous lymphomas using the standardized BIOMED-2 polymerase chain reaction protocols]

The European Biomedicine and Health (BIOMED-2) Concerted Action Project BMH4-CT98-3936 has defined standardized protocols for polymerase chain reaction (PCR) amplification of different loci of the T-cell receptor (TCR) and immunoglobulin (Ig) genes with a view to achieving greater sensitivity and specificity in the assessment of clonality of lymphoid neoplasms. To assess T-cell clonality, analysis of TCRbeta gene and TCRdelta rearrangements (useful in cases of Tgammadelta + cell neoplasms) is proposed alongside that of TCRgamma. For analysis of B-cell clonality, along with the framework (FR) III segment of the IgH gene, other segments are studied (FRI, FRII) in addition to Igl and Igk genes or incomplete DJ rearrangements of the IgH gene and the k deleting element. The results of the amplification are read using automatic reading systems (GeneScan) or using a heteroduplex system.

Clinical characteristics and psychopathological profile of patients with vulvodynia: an observational and descriptive study

BACKGROUND

Vulvodynia is a fairly common dermatological symptom that often interferes with the personal, social and working activities of affected women and results in a significant loss of their quality of life. It is a persistent and tedious clinical disorder which is often resistant to conventional treatments.

OBJECTIVES

The aim of this study is to evaluate the main clinical signs, associated psychopathological disorders and outcome after antidepressant treatment of patients with vulvodynia.

METHODS

Eighty patients were included. Clinical characteristics and psychopathological profiles were determined by appropriate instruments. The improvement of clinical symptoms after combined antidepressant drug therapy was also evaluated.

RESULTS

Pain (70%), burning (63.7%), dyspareunia (57.5%) and stinging (56.2%) were the most commonly reported symptoms. Most patients (56.5%) showed anxiety, and 52.2% of them were reported as having a depression disorder. When evaluated by psychometric tools, 81.4% of patients scored >150 on the Life Event Scale, which means a risk >50% of suffering an illness in the near future, and patients' scores in the Dermatology Life Quality Index showed higher values than the mean of the Spanish validation group. After 6 months of combined treatment with escitalopram (10-20 mg/day), perfenazine (2-4 mg/day) and amytriptiline (10 mg/day), a complete remission of the clinical symptoms was achieved in 41% of patients. In contrast, only 12% of patients who did not follow drug treatment reported a complete resolution of the clinical symptoms.

CONCLUSIONS

Our results seem to confirm that vulvodynia is associated with psychiatric co-morbidity such as stress and depression. The study highlights that the psychiatric treatment may be a useful option to improve clinical symptoms. Whether these patients should be evaluated for depression or be referred to a psychiatrist, remains to be investigated.

Multifocal segmental hyperthermic and hyperhidrotic naevus flammeus: a peculiar variant of eccrine angiomatous hamartoma?

Eccrine angiomatous hamartoma (EAH) is a lesion that tends to appear as a plaque or nodular single lesion that may be painful and/or hyperhidrotic. Histopathologically, EAH is manifested by lobules of mature eccrine glands and ducts closely associated with well-differentiated, thin-walled blood vessels. Rarely, EAH can present as a macular hyperhidrotic lesion following a segmental distribution.

Kraft mill sludge to improve vegetal production in Chilean Andisol

The effect of kraft mill sludge addition (25 to 75 ton/ha) to soil derived from volcanic ashes (Andisol) on wheat (Triticum aestivum L.cv. Puken) biomass production, and in the nutrient absorption by the plants was evaluated. Respiration activity and seed germination tests were carried out on the soil/sludge mixtures, in order to evaluate possible toxic effects due to the sludge addition to the soil. Soil without sludge was used as a control treatment. The plants were grown in a greenhouse (25 degrees C, 14 h-photoperiod) during 120 days, then the plants were collected and dried at 65 degrees C for 72 h for the determination of biomass production (root and aerial) and analyzed for mineral content (Ca, Mg, K and P). The mixtures of soil/sludge showed no toxicity. Seed germination and respiration activity increased with the increment of the sludge. The accumulated CO2 in the soil without sludge was 41.66 mg CO2/100; this value shows a low microbial activity. The biomass increased with the increment of sludge addition to the soil and five times more biomass was obtained when 75 ton/ha sludge was added to the soil. The nutrient absorption efficiency was also improved with the sludge addition.

Expression of androgen, oestrogen alpha and beta, and progesterone receptors in the canine prostate: differences between normal, inflamed, hyperplastic and neoplastic glands

The expression of receptor for androgen (AR), oestrogen alpha and beta (ERalpha and ERbeta) and progesterone (PR) was examined immunohistochemically in canine prostate specimens (normal, hyperplastic, inflamed [prostatitis] or neoplastic). AR immunolabelling was seen in 100% of epithelial cells of normal and hyperplastic tissue, the corresponding figures for inflamed and carcinomatous tissue being 74% and 65%, respectively. ERalpha labelling was seen in 85% of epithelial cells in normal prostate glands, the corresponding figures for hyperplastic, inflamed and neoplastic glands being 35%, 22% and 12%, respectively. ERbeta labelling was seen in 85% of epithelial cells of normal glands and in about 70% of such cells in glands showing pathological changes. On the other hand, PR expression (weak) in normal glands was observed in fewer epithelial cells (44%) than in hyperplastic (70%), inflamed (62%) or neoplastic (64%) glands.

Recurrent and self-healing cutaneous monoclonal plasmablastic infiltrates in a patient with AIDS and Kaposi sarcoma

Infection with human immunodeficiency virus (HIV) increases the risk of developing non-Hodgkin lymphoma. Plasmablastic lymphoma (PBL) is a rare variant of diffuse large cell lymphoma that often involves the oral cavity of HIV+ patients. It is characterized by immunoblastic morphology and plasma cell phenotype. Cutaneous involvement in PBL appears to be rare. We report a 44-year-old man with AIDS and Kaposi sarcoma (KS) previously treated with doxorubicin who, following treatment with highly active antiretroviral therapy, developed an erythematous infiltrated nodule on the right arm. Histology showed subcutaneous fat necrosis and clusters of atypical large plasma cells (plasmablastic cells). Immunohistochemistry revealed lambda light chain restriction. Epstein-Barr virus (EBV) mRNA was detected by in situ hybridization within the plasmablastic cells. Polymerase chain reaction amplification with specific primers for human herpesvirus 8 (HHV-8) performed on the skin biopsy specimen detected a specific band. A complete screening (bone marrow biopsy, computed tomographic scan, radiological survey) disclosed no abnormalities. The lesion resolved spontaneously after 3 months. Two years later an infiltrated plaque developed on the abdominal wall. The clinical and histopathological features of this new lesion were similar to those observed 2 years previously. No evidence of extracutaneous involvement was detected. The lesion again resolved spontaneously after 25 days. PBL may be seen in patients with transplants or receiving chemotherapy, but is usually observed in patients with advanced AIDS. The observation of recurrent self-healing EBV- and HHV-8-associated cutaneous monoclonal plasmablastic infiltrates, in a patient with AIDS and KS, expands the clinical spectrum of AIDS-associated plasmablastic lymphoproliferative disorders.

Aggressive multifocal Buruli ulcer with associated osteomyelitis in an HIV-positive patient

Mycobacterium ulcerans infection causes a skin disease known as Buruli ulcer (BU), a disorder manifested usually as a solitary and painless nodule or papule that progresses to massive necrotizing destruction and cutaneous ulceration. When healing occurs, it often results in disabling deformities. Buruli ulcer is considered the third most common mycobacterial disease in immunocompetent people, after tuberculosis and leprosy. Although the emergence of Buruli ulcer in Western African countries over the past decade has been dramatic, it has been scarcely reported in industrialized countries. We report a patient from Equatorial Guinea who was human immunodeficiency virus-positive, presenting aggressive and multifocal BU associated with an underlying destructive osteomyelitis, in which only an aggressive surgical approach yielded to a resolution of the disease. In a global world, with increasing migratory population fluxes, an increased awareness of dermatologists regarding the clinical, histopathological and microbiological features of BU is important in order to avoid significant delays in diagnosis and treatment.

Primary cutaneous B-cell lymphoma (marginal zone) with prominent T-cell component and aberrant dual (T and B) genotype; diagnostic usefulness of laser-capture microdissection

The presence of a dominant B- or T-cell clone is an important diagnostic criterion for distinguishing cutaneous lymphomas from lymphoid reactive infiltrates. Rarely, a combined B- and T-cell rearrangement can be detected from a single sample. In such instances, genotypic analysis does not permit differentiation of the coexistence of a T- and B-cell lymphoma from a single clone harbouring a monoclonal rearrangement for both immunoglobulin heavy chain and T-cell receptor genes. We herein report a case of a skin tumour consistent with a dense cutaneous lymphoid infiltrate showing a double prominent B- and T-cell component. A dual B- and T-cell clonality was detected by polymerase chain reaction from whole-tissue DNA sample. Genotypic analysis with DNA, obtained after laser-assisted microdissection from the B-cell population, again showed both T- and B-cell monoclonal rearrangements. Conversely, the microdissected T-cell population did not reveal a clonal pattern. The diagnosis of cutaneous B-cell lymphoma with a dual B- and T-cell genotype was established. This description illustrates the diagnostic usefulness of laser-capture microdissection in cutaneous lymphomas presenting dual genotype.

[Different antibiotic resistance mechanisms associated with integrons in clinical isolates of Salmonella typhimurium]

Antibiotic resistance in clinical isolates of Salmonella typhimurium has steadily risen in recent years. Some of the resistance genes may be carried into integrons. In this study, integrons, both from 10 epidemiologically related and unrelated S. typhimurium clinical isolates, were characterized, showing that epidemiologically different strains can carry the same integron, and that epidemiologically related strain can carry different integrons. Among the resistance genes detected in this study were genes encoding b-lactamases (bla(oxa-30) in two strains, and bla(pse-1) in five strains, one of which was carrying this cassette in two different integrons); aminoglycoside-modifying enzymes (aadA2 in four strains, one of which was carrying this cassette in two different integrons, and aadA1 in six strains); as well dihydrofolate reductases (dfrAI in three strains).

[Ursodeoxycholic acid treatment shortens the course of cholestasis in two patients with benign recurrent intrahepatic cholestasis]

INTRODUCTION

Benign recurrent intrahepatic cholestasis (BRIC) is a rare autosomal-crecessive or sporadic disorder, characterized by repeated episodes of unexplained cholestasis followed by prolonged asymptomatic periods.

CASE REPORT

We present two male patients aged 12 and 15 years old who initially presented cholestasis and who had no family history of liver or biliary disease. Typically, alkaline phosphatase and bilirubin levels were elevated, with a slight increase in transaminases and gamma-glutamyltransferase. In both patients biliary tract disease was ruled out by endoscopic retrograde cholangiopancreatography and magnetic resonance cholangiography while no significant abnormalities of the liver parenchyma were found on liver biopsy. Early treatment with ursodeoxycholic acid (UDCA) reduced the duration of the cholestasis episode compared with that of other episodes in which the patient had received other treatment or the treatment was late (1 or 2 months vs 4 months in patient 1 and 1-3 months vs 5 months in patient 2, respectively).

DISCUSSION

Consensus is lacking on the treatment of BRIC although several treatment have been used. UDCA could be effective in increasing bile acid secretion and in reducing serum bilirubin levels. In the two patients described, the initial dosage was 15 mg/kg/day, which was subsequently maintained at 6 mg/kg/day, which was subsequently maintained 6 mg/kg/day until biochemical parameters returned to normal. Nevertheless, larger studies are required to confirm that UDA shortens episodes of cholestasis in BRIC.

Sézary syndrome and related variants of classic cutaneous T-cell lymphoma. A descriptive and prognostic clinicopathologic study of 29 cases

Large series of patients with Sézary syndrome (SS), the leukemic variant of cutaneous T-cell lymphoma (CTCL), have been reported infrequently because of its low incidence. Here we recorded several clinical, histopathological and immunophenotypical features of 29 cases of leukemic CTCL patients from four Dermatology Departments of Catalonia, Spain, and analyzed their prognostic value. Clinical data included sex, age, delay of SS diagnosis, previous diagnosis of lymphoma, B-symptoms, type of skin lesions, peripheral adenopathy, histologic evaluation of lymph node biopsy, visceral involvement, percentage of circulating Sézary cells, serum LDH and beta-2-microglobulin levels, first treatment and response, disease-free interval, further therapies and survival. Histopathological data examined were epidermotropism, depth and thickness of the infiltrate, cell size, adnexal involvement, presence of granuloma, eosinophils and plasma cells, mitotic rate. The percentage of CD45Ro, CD43, CD20, CD30 and CD8 positive dermal cells were also recorded. Survival showed a mean actuarial risk of 57% at 3 years and 38% at 5 years, with a median survival of 48 months. Analysis of actuarial survival demonstrated as following as features linked with a bad prognosis: fast evolution of the disease (from symptoms onset up to diagnosis) (p = 0.0274) raised levels of serum lactate dehydrogenase (p = 0.0379) and beta-2-microglobulin (p = 0.0151), the latter being the most important prognostic factor. In conclusion although SS had been traditionally considered as a low-grade lymphoma, the present study agrees with the recent classification rating SS as an aggressive type of CTCL with a poor prognosis. Our results show that some simple clinical and blood test data can be useful as prognostic indicators in this disease.

Primary cutaneous marginal zone B-cell lymphoma: a clinical, histopathological, immunophenotypic and molecular genetic study of 22 cases

BACKGROUND

Primary cutaneous marginal zone B-cell lymphoma (MZCL) has recently been described. Differentiation from follicular centre cell lymphomas and lymphocytomas is often difficult due to insufficient experience and a lack of large series of patients.

OBJECTIVES

To characterize primary cutaneous MZCL better, we report clinical, histopathological, immunophenotypic and molecular genetics features in a series of 22 patients.

METHODS

All patients were treated and followed up at the same institution. Diagnosis of MZCL was based on the World Health Organization classification criteria. All samples were routinely tested with a wide panel of monoclonal antibodies. DNA was extracted from every sample following standard methods. IgH rearrangement and t(14;18)(q32;q21) studies were performed in all samples.

RESULTS

Twenty-two patients (20 men, two women; mean age 50 years, range 24-77) were included. The mean follow-up was 43 months. Seventy per cent of patients presented with characteristic skin lesions on the trunk or extremities, consisting of deep red to violaceous infiltrated plaques, nodules or tumours frequently surrounded by diffuse or annular erythema. Four patients presented with lesions on the head and neck area. Two patients had disseminated skin lesions. The main histopathological features were non-epidermotropic, dense lymphocytic infiltrates mainly distributed in a nodular pattern. Adnexal involvement was usually present, with eventual formation of lymphoepithelial complexes. Cytologically, the infiltrate was polymorphous with marginal zone B cells and B-monocytoid cells. Blastoid CD30+ cells were often observed. Colonized reactive germinal centres and lymphoplasmocytoid differentiation were frequently present. Neoplastic cells were CD20+, CD79a+, CD5- and CD10-. Monotypic expression of light chains was observed in 18 cases (13 kappa; five lambda). Clonal IgH rearrangements were detected in 14 cases. The bcl-2 mutation t(14;18)(q32;q21) was demonstrated in two cases. Most patients were treated with local radiotherapy. Complete response rate with this approach was 100%. Six patients (27%) had skin recurrences from 6 months to 8 years after first treatment. Five patients (23%) had extracutaneous involvement. Two of them had a large cell transformation and one died of lymphoma. Three of four patients with head and neck presentation developed extracutaneous disease.

CONCLUSIONS

MZCL appears to be a well recognizable entity, clinically, histologically and immunophenotypically. Although prognosis is generally good, the disease has potential for skin as well as extracutaneous recurrences. Large cell transformation and head and neck presentation may be associated with a worse prognosis.

Invisible mycosis fungoides: A diagnostic challenge

We describe a 76-year-old woman who presented persistent generalized pruritus as the only cutaneous manifestation of a cutaneous T-cell lymphoma (mycosis fungoides). No cutaneous lesions were observed throughout the patient's course. Skin biopsies obtained from normal-looking pruritic skin revealed a discrete perivascular lymphocytic infiltrate in the upper dermis and focal intraepidermal clusters of atypical lymphoid cells (Pautrier's microabscesses). PCR analysis of TCR-gamma gene disclosed a monoclonal T-cell rearrangement. Sequencing of the PCR monoclonal product identified the J(8)V(2)C(2) TCR gene rearrangement. This observation illustrates the existence of a peculiar and exceedingly rare form of mycosis fungoides characterized only by persistent pruritus unresponsive to several therapeutic approaches. The diagnostic difficulties of this rare variant are stressed.