Infantile Henoch-Schönlein purpura

Henoch-Schönlein purpura is a common cause of vasculitis in children. This condition is unusual in infants and children younger than 2 years. We describe a 4-month-old infant with infantile Henoch-Schönlein purpura and review the clinical spectrum, differential diagnoses, and the histopathologic features of the disease. Its relations to Henoch-Schönlein purpura in older children are discussed.

Dopaminergic function and the cortisol response to dexamethasone in psychotic depression

1. It has been hypothesized that psychotic symptoms in depression may be due to increased dopamine activity secondary to hypothalamic-pituitary-adrenal (HPA) axis overactivity. 2. To test this hypothesis, the authors examined the cortisol response to dexamethasone suppression test (DST, 1 mg orally) and multihormonal responses to apomorphine (APO, 0.75 mg s.c.)--a dopamine agonist--in 150 drug-free hospitalized patients with DSM-IV major depressive episode with psychotic features (MDEP, n=35), major depressive episode without psychotic features (MDE, n=74), or schizophrenia paranoid type (SCZ, n=41), and 27 hospitalized healthy controls (HCs). 3. MDEPs showed increased activity of the HPA system (i.e. higher post-DST cortisol levels) than HCs, SCZs and MDEs. However, there were no differences in adrenocorticotropic hormone (ACTH), cortisol, prolactin and growth hormone (GH) responses to APO between MDEPs and MDEs and HCs. On the other hand, SCZs showed lower APO-induced ACTH stimulation and a higher rate of blunted GH than HCs, MDEs and MDEPs, suggesting a functional alteration of the hypothalamic dopamine receptors in SCZs. 4. In the total sample and in each diagnostic group, DST suppressors and non-suppressors showed no differences in hormonal responses to APO. 5. These results suggest a lack of causal link between HPA axis hyperactivity and dopamine dysregulation. In contrast to schizophrenia, psychotic symptoms in depression seem not to be related to dopamine function dysregulation.

Thyroid axis activity and serotonin function in major depressive episode

Recent studies in depression have reported alterations in both hypothalamic-pituitary-thyroid (HPT) axis activity and serotonin (5-HT) function; however, the functional relationships between the two systems have not been well defined in patients with major depressive episode. Thyrotropin (TSH) response to 0800 and 2300 h protirelin (TRH) challenges, and adrenocorticotropic hormone (ACTH), cortisol, and prolactin (PRL) responses to D-fenfluramine (D-FEN), a specific 5-HT releasing/uptake-inhibiting agent, were examined in 60 drug-free DSM-IV major depressed inpatients and 20 hospitalized controls. Compared with controls, patients showed lower basal serum 2300 h TSH, 2300 h maximum increment in serum TSH above baseline (delta TSH) and difference between 2300 h delta TSH and 0800 h delta TSH (delta delta TSH) levels. The hormonal responses to D-FEN (i.e. delta ACTH, delta cortisol and delta PRL) were interrelated. No significant difference in basal and post-D-FEN ACTH, cortisol or PRL values were found between controls and patients. A negative relationship between hormonal responses to D-FEN and 2300 h delta TSH and delta delta TSH values was observed in the depressed group. When patients were classified on the basis of their delta TSH test status, patients with reduced delta delta TSH values (i.e. with HPT axis abnormality) had hormonal D-FEN responses comparable to those of controls. Patients with normal delta delta TSH values (i.e. without HPT axis abnormality) showed lower ACTH, cortisol and PRL responses to D-FEN than controls and patients with abnormal delta delta TSH values. These results suggest that: (1) pathophysiological mechanisms other than 5-HT dysregulation may be involved in TSH blunting in major depressed patients; (2) 5-HT function is reduced in some depressed patients, especially those without HPT axis abnormality; and (3) HPT dysregulation may be regarded as a compensatory mechanism for diminished central 5-HT activity.

Variations in etiology of ventilator-associated pneumonia across four treatment sites: implications for antimicrobial prescribing practices

This retrospective multicenter study compared microorganisms documented by quantitative cultures from bronchoscopic samples in episodes of ventilator-associated pneumonia (VAP) from three different institutions in Barcelona (B), Montevideo (M), and Seville (S). The observations were compared with the findings reported by Trouillet and coworkers (AJRCCM 1998;157:531-539) in Paris (P). The objective was to evaluate whether a classification of etiologies of VAP in four groups, based on the number of ventilation days and previous antimicrobial use, might contribute to establishing generalized guidelines for empirical therapy. Significant variations in etiologies (p < 0.05) were found in all of the microorganisms isolated from VAP episodes across three treatment sites when compared with the reference site (P). In Group 1 (< 7 d and absence of antibiotics), Pseudomonas aeruginosa remained extremely infrequent (3 of 89, 3.3%) in the joint category, whereas the incidence of Acinetobacter baumannii was significantly higher, owing to M findings. On the other hand, one site (B) had a significantly lower incidence of multiresistant pathogens (Methicillin-resistant Staphylococcus aureus [MRSA] and nonfermenters other than P. aeruginosa), even in Group 2 (< 7 d and antibiotics), Group 3 (>/= 7 d and absence of antibiotics), and Group 4 (antibiotics and >/= 7 days). Similar findings were documented when episodes were grouped according to Groups 1 and 3 of the ATS guidelines. We conclude that causes of VAP varied markedly across four treatment sites, resulting in the need for large-scale variations in antimicrobial prescribing practices. Instead of following general recommendations, antimicrobial prescribing practices for VAP should be based on up-to-date information of the pattern of multiresistant isolates from each institution.

Structural elements common to mitosis and apoptosis

Both mitotic and apoptotic cells display hypercondensation of the chromatin and loss of the nuclear envelope (Lazebnik et al., 1993). Herein, we describe a third similarity between the two processes. We have observed, initially in apoptotic cells of the PC-12 lineage clusters of 40-60 (approximately 50) nm vesicles adjoined by a minor contingent of tubule vesicular elements of 100-200 nm which are indistinguishable from their vesicular counterparts in mitotic PC-12 cells. The clusters of approximately 50 nm vesicles were subsequently observed in all studied rat tissue cells in apoptosis (plasma cells and macrophages, secretory epithelial cells from pancreatic acini, ventral lobe of prostate and mammary gland). Clusters of approximately 50 nm vesicles comparable to those of the PC-12 cells were found in HeLa cells treated with human alfa TNF, in WEHI-3 cells exposed to VM 26 (a teneposide) (Sesso et al., 1997) and in HL-60 cells treated with thapsigargin. PC-12 and HeLa cells affixed to coverslips were double labelled and examined with the fluorescence microscope to reveal simultaneously the disposition of the chromatin with Hoechst stain and the distribution of the fluorescence of Golgi or of Golgi-associated proteins. A common pattern of fluorescence was observed in a minor proportion of apoptotic cells using three different antibodies used. The label frequently appeared as finely dispersed granules in the cytoplasm. In some apoptotic cells, relatively coarse granules were observed. This pattern of label distribution is compatible with the disposition of vesicular clusters we have encountered in apoptotic PC-12 cells sectioned serially or semi serially. In such sections of both mitotic and apoptotic PC-12 cells, we noticed that the conglomerates of 50 nm vesicles were frequently associated with cisternae of the rough ER. Vesicles of similar size were also noted pinching off from the extremities of Golgi cisternae reduced in size. These cisternae diminish in length and width when they are in the process of disassembling at the very beginning of mitosis and in apoptosis.

Focal segmental glomerulosclerosis in children with acute lymphocytic leukemia: case reports and review of literature

PURPOSE

To report the occurrence of focal segmental glomerulosclerosis (FSGS) in children with acute lymphocytic leukemia (ALL), discuss pathogenesis and problems in management.

PATIENTS AND METHODS

Progressive renal dysfunction developed in two adolescent black girls with high-risk ALL who underwent renal biopsies that were consistent with FSGS. In both patients, no known etiologic factors, such as systemic lupus erythematosus, poststreptococcal glomerulonephritis, sickle cell anemia, or acquired immunodeficiency syndrome, were evident. FSGS induced by Adriamycin (Pharmacia & Upjohn, Columbus, OH) has been observed experimentally in rats. The patients had received anthracyclines and methotrexate, a known nephrotoxic chemotherapeutic agent.

RESULTS

One patient progressed to chronic renal failure and required prolonged dialysis followed by renal transplantation, though the leukemia remained in remission. The other patient is also in remission and on maintenance treatment for leukemia. She has persistent proteinuria and is currently undergoing a trial of high-dose steroid therapy.

CONCLUSION

The combination of FSGS with leukemia poses a management challenge to the clinician in terms of further treatment with potentially nephrotoxic drugs, complications of nephrotic syndrome (including infections), and timing of renal transplantation. Future studies should address whether FSGS represents a glomerular response to anthracycline-induced injury in susceptible black persons.

Role of MRI in diagnosis of childhood sarcoidosis with fever of unknown origin

Childhood sarcoidosis is a disease with multisystem organ involvement, and initial presentation as fever of unknown origin (FUO) is relatively common. We describe herein three children (aged 9, 7, and 11 years) with sarcoidosis who were seen initially with FUO. Common clinical and laboratory features include fever of > 2 weeks' duration, weight loss, fatigue, leg pain, anemia, increased erythrocyte sedimentation rate, elevated immunoglobulin G level, negative antinuclear antibodies and rheumatoid factor, and negative purified protein derivative and Candida skin tests. Two patients had iridocyclitis, one had hilar adenopathy, and two had angiotensin-converting enzyme serum levels. All three had no evidence of pulmonary infiltrates on chest radiographs. Bone marrow biopsies for all three were normal, and with no evidence of malignancy. Plain radiographs of the lower extremities and bone scan were normal. Magnetic resonance imaging (MRI) of the lower extremities revealed intact bone architecture and multifocal nodular lesions within the marrow. Bone biopsy from the tibia performed on two patients showed normal bone trabeculae and a solitary noncaseating epithelioid cell granuloma. Noncaseating granuloma was found on reevaluation of the bone marrow biopsy in the third patient. All three patients had negative marrow stains and cultures for fungi and mycobacteria. We conclude that MRI was very useful in the diagnosis of sarcoidosis in children with FUO.

[Diagnosis of pneumonia in intubated patients: a controversy without resolution?]

There is yet no accurate, fast, innocuous and inexpensive method for the diagnosis of pneumonia associated to ventilation (NAV). Here we analyse three diagnostic lines of increasing level of certainty. CLINICA METHOD: Associates radiological image, pus in the trachea and temperature changes and or leukocytosis. Although it is quite sensitive in the absence of distress, is it not very specific. Nevertheless, it must be appreciated for its function as a guide, recalling that in its absence bacterial counts are of scarce value. QUANTITATIVE BACTERIOLOGICAL STUDIES OF DEEP SPECIMENS: Broncho-alveolar lavage (BAL) and protected brush (PB) serve a double objective: to discriminate colonisation from infection, and the identification of the etiological agent. The sensitivity of BAL/PB is approximately 70% while specificity is close to 80%. The method performs better in the absence of previous antibiotic therapy. HISTOLOGICAL DIAGNOSIS: Almost never obtained while the patient is alive, it is nevertheless the golden standard. The absolute diagnosis of NAV is: histological for pneumonia, with a positive tissue culture. USE OF DIAGNOSIS IN THERAPY: Empirical treatment results in a 40% failure rate. The specific treatment requires therapeutic changes in more than 1/3 of cases. Treatment when the micro-organism is known is followed by longer survival. Perhaps the correct approach would be: early empirical treatment after taking deep samples and correction according to the results obtained.

Risk factors for infection by Acinetobacter baumannii in intubated patients with nosocomial pneumonia

STUDY OBJECTIVE

To investigate the epidemiology of infection by Acinetobacter baumannii in patients with ventilator-associated pneumonia (VAP).

DESIGN

Prospective clinical study.

SETTING

Three medical-surgical ICUs in teaching hospitals.

PATIENTS

We followed up 707 mechanically ventilated patients and 148 episodes of VAP with etiologic diagnosis.

RESULTS

A baumannii was isolated in 12 (8.1%) episodes in 148 patients. Five of these episodes were directly responsible for death. Using logistic regression analysis, the risk of VAP due to A baumannii was found to be high in patients with neurosurgery (odds ratio [OR]=10.03; 95% confidence interval [CI]=1.55 to 64.90), ARDS (OR=9.73; 95% CI=1.60 to 59.24), head trauma (OR=5.17; 95% CI=0.88 to 30.34), and large-volume pulmonary aspiration (OR=2.90; 95% CI=0.80 to 10.53).

CONCLUSIONS

Intubated patients who develop pneumonia and have any of the above factors are at an increased risk of Acinetobacter infection.

Essential thrombocythemia in an infant

PURPOSE

To report the unusual occurrence of essential thrombocythemia (ET) in a 5-month-old infant.

PATIENTS AND METHODS

The child was referred by her pediatrician for a high platelet count detected on routine blood testing. The child was asymptomatic except for failure to thrive. Diagnostic tests to rule out secondary causes of thrombocytosis as well as myeloproliferative syndrome were done.

RESULTS

The platelet count persisted at > 1,000,000/microliters, and no secondary cause could be established. The bone marrow aspirate and biopsy showed normal cellularity, no fibrosis, orderly maturation, and normal morphology of all three cell lines, with only an increase in the number of megakaryocytes. A diagnosis of ET was established as per the Polycythemia Vera Study Group criteria. In view of the young age of the patient and asymptomatic course of the disease, we decided to observe the child only, reserving antiplatelet agents for use in the event of a thromboembolic or hemorrhagic episode.

CONCLUSIONS

This is the youngest known child with ET. We believe that conservative observation is warranted in an asymptomatic child. The child is currently doing well and is asymptomatic 4.5 years after diagnosis.

Abdominal aortic aneurysm associated with childhood sarcoidosis

Childhood sarcoidosis is a rare disease with multisystemic organ involvement. A wide spectrum of vasculitides, including large vessel involvement, have been reported in childhood sarcoidosis. We describe a 7-year-old boy with childhood sarcoidosis who presented with prolonged fever, iritis, and abdominal aortic aneurysm. He underwent successful surgical repair of the abdominal aortic aneurysm and followup for 12 months was uneventful. This is first report of abdominal aortic aneurysm complicating childhood sarcoidosis.

Renal collecting duct carcinoma in an 8-year-old child

A fatal collecting duct carcinoma, presenting with pleural metastases, arose from the right kidney in an 8-year-old child. A distal nephron origin of the tumor is supported by positive tumor staining with Ulex europaeus and Arachis hypogaea, and a lack of staining with Tetragonolobus lotus. The ultrastructural features of short stubby microvilli, smooth basal cell membranes, and lateral membrane infoldings also support a distal nephron origin (inner most inner medullary collecting duct). This rare childhood renal neoplasm behaved similarly to that reported in adults with metastatic disease at presentation and a short fatal clinical course.

Trisomy 8 in alveolar soft part sarcoma

Cytogenetic studies were performed on an alveolar soft part sarcoma of a 6-year-old boy. An extra chromosome 8 was present in 26 of 28 metaphases analyzed.

Case report: steroid sparing effect of intravenous gamma globulin in a child with necrotizing vasculitis

This article reports the case of a boy aged 2 years 6 months, who had fever, arthritis, and necrotizing cutaneous vasculitis. Evaluation revealed no evidence of direct infectious causes. However, high anti-streptolysin and streptozyme titers during the acute phase support the possibility that streptococcal infection played an important role in the pathogenesis of this disease. The patient's condition improved significantly with the administration of prednisone. However, several attempts to diminish the prednisone dose resulted in relapses. Subsequently, the prednisone was successfully tapered and discontinued after intravenous gamma globulin administration. It is recommended that intravenous gamma globulin should be considered before immunosuppressive therapy in the treatment of necrotizing vasculitis.

Nephroblastoma and end-stage renal failure with bilateral cystic kidneys

A child of 10 years 5 months presenting with chronic renal failure had bilateral cystic kidneys. Biopsy of a right lower-pole solid mass revealed nephroblastoma. At bilateral nephrectomy, both kidneys were both replaced by variable-sized cysts with a unifocal nephroblastoma on the right. Renal failure with nephroblastoma is uncommon and is usually either a manifestation of the Drash syndrome or a complication of chemotherapy. The need to assess both kidneys in a child with any other renal abnormality in addition to a renal mass should always be considered.

Aggressive giant cell fibroblastoma with a balanced 17;22 translocation

Cytogenetic analysis of an aggressive giant cell fibroblastoma in a 15-month-old male revealed the following balanced translocation: t(17;22)(q21.33;q13.1). This is the first cytogenetic report on this early childhood tumor.

Dermatofibrosarcoma protuberans with 46,XY,t(X;7) abnormality in a child

A 9-year-old child with dermatofibrosarcoma protuberans demonstrated a balanced translocation, 46,XX,t(X;7)(q21l2;q11.2), in the untreated tumor, an abnormality not previously reported. Unlike seven of eight other reports of dermatofibrosarcoma protuberans, no ring chromosomes were present.

A three-dimensional reconstruction study of the rough ER-Golgi interface in serial thin sections of the pancreatic acinar cell of the rat

Distinctive views of the tubulo-vesicular elements interposed between the endoplasmic reticulum (ER) and the Golgi apparatus were obtained in thin sections. The tubules that protrude from the transitional rough ER (tRER) are of dissimilar length. The numbers of tubules and of the nearby omega- and pear-shaped profiles decrease after fasting and are partially restored by refeeding. This formation is designated herein as the budding chamber of the tRER. Close to the budding chamber, clusters of 56 nm diameter vesicles are consistently observed. In some of the cells, convoluted tubules appear enmeshed with the presumptive transport vesicles of 56 nm diameter and with irregular, vesicular formations. Apparently structureless, electron-lucent ellipsoidal areas are found adjacent to these membranous elements. Serial and semi-serial sections show that the budding chamber, the sinuous tubules, the irregular vesicles, the structureless regions and the 56 nm vesicles fill tunnel-like spaces limited by the outermost Golgi cisterna (OGC) on one side and by the tRER on the other. Curved tubules appear to link the lumen of the OGC with that of smooth membranous occupants of these tunnel-like spaces. A presumptive luminal connection between these membranous occupants and the tubules of the budding chamber can also be seen. The predominant configuration of the OGC is that of a perforated, flat saccule. However, OGC regions exhibiting progressively lower densities of fenestrae, including smooth surfaced sectors eventually accumulating an intraluminal content are seen. Two such dilated, saccular portions of the OGC were analyzed through reconstruction of serial sections. Bundles of microtubules run closely apposed to the cis side of the OGC.

An application of mathematical models for decision making to the selection of policies on testing for drug use

The object of the paper is to provide the basis to decide whether testing for drug use should be used, taking into consideration individual and social benefits and costs that the results of the tests could originate. In the analysis, special attention is paid to the fact that the actual costs of the tests themselves are not the most important elements of the social costs of a testing program. The most important costs are those generated by the defective results of the tests. They can provide false positive results, meaning that a nonuser is identified as a user, or false negative results in which a user is not identified as such. Social costs of the false positive results range from lowered worker morale to legal suits, while the false negative results eliminate any benefit that the identification of drug users could have. Combining all these elements, Correa and Woods specify a mathematical procedure as a decision tool to be used for determining whether a testing program should be implemented in specific industries or groups of industries. A complete implementation of the model is not carried out due to the lack of the required statistical information. However, preliminary trials showed that the conceptual and mathematical framework is operational, and that the model prepared could be used as a guideline for collecting the most appropriate data for decision making.

Visual evoked potentials and brain stem auditory potentials in Friedreich's ataxia--a longitudinal study

Six patients with Friedreich's ataxia, 4 males and 2 females, their ages ranging from 13 to 33 years, were studied. The early manifestations started between age 7 and 13 with an evolution time between 6 and 20 years. Serial visual and brain stem auditory evoked potential recordings were made. A progressive increase in latency, reduction in amplitude and in latency inter-ocular difference of P100 were observed. The pattern of the reversal checker-board visual evoked potential was preserved. A disorganized BAEP pattern, a well defined potential I, a very small potential V and a delay in the interpeak latency were constant findings. The assumption is made of a progressive involvement of both visual and central auditory pathways. Pathophysiological mechanisms are discussed.

Nutrition and fertility: some iconoclastic results

In this paper, the evidence available is used to conclude that, as levels of nutrition increase from insufficient to excessive, fertility first increases and then decreases. This suggests that the relationship between fertility and nutrition has the shape of an inverted U. Next, the hypothesis is explicitly tested using countries as units of observation. In the statistical analysis, the possibility of spurious relationships is carefully controlled. The results strongly support the hypothesis that, for existing levels, additional intake of nutrients decreases the levels of fertility.