[Morning changes in the sigma ESR, erythrocyte sedimentation rate (Westergren) and C-reactive protein]

A comparative study of the morning variation of the Sigma and Westergren sedimentation rates, and C-reactive protein was undertaken in 90 patients with osteoarticular disease (measurements at 07:00, 09:00, 10:00, and 12:00). The mean values of all three tests were elevated at 07:00 in patients with inflammatory disease, and no significant variation was observed in the Westergren sedimentation rate or C-reactive protein throughout the morning, irregardless of whether an anti-inflammatory agent was used. On the other hand, there was a very significant increase in the Sigma sedimentation rate at 09:00 in untreated patients (p less than 0.0001, n = 24). This morning increase of the Sigma sedimentation rate was not related to food intake, identical value being obtained in fasting or postprandial samples from the same patients. The Sigma sedimentation rate at 09:00 was significantly reduced however, in patients treated with an effective level of an anti-inflammatory agent (p less than 0.001, n = 32). This decrease varied in size and duration depending on the anti-inflammatory agent used. The existence of a circadian rhythm of the Sigma sedimentation rate which can be reversed with anti-inflammatory drug usage is helpful in understanding the chronobiologic aspects of the inflammatory process. Numerous therapeutic applications can be foreseen.

Isolated abducens nucleus damage due to histiocytosis X. Electro-oculographic analysis and physiological deductions

A case of complete rightward conjugate gaze paralysis, with electro-oculographic recordings, is reported. The only additional feature on clinical examination was a right infranuclear facial paresis. Radiographs of the chest showed multiple infiltrates in both lung fields; lung biopsy with ultrastructural study led to the diagnosis of histiocytosis X. A CT scan showed a single small tumour-like lesion, hyperdense and clearly defined, lying centrally in the fourth ventricle with a small ventral extension located just to the right of the midline. With appropriate treatment all the clinical signs rapidly subsided, together with the disappearance of the right ventral extension of the lesion visible on the CT scan. The clinical and CT scan data suggested that the initial parenchymatous damage almost exclusively involved the right abducens nucleus, a structure which is very rarely affected in an isolated manner. Both main clinical features of the abducens nucleus syndrome which distinguish it from the recently described paramedian pontine reticular formation syndrome were present, namely absence of all ipsilateral conjugate movements and persistence of ipsilaterally directed saccades in the contralateral hemifield of movement. Furthermore, differences between peak velocities of both eyes in oculocephalic movements suggested that a pathway analogous, at least functionally, to the ascending tract of Deiters described in the cat and in the monkey may exist in man. Lastly, some recent clinical data concerning this unusual cause of CNS damage are briefly reviewed.

Pontine metastasis with dissociated bilateral horizontal gaze paralysis

A clinicopathological case of pontine metastatic tumour is reported with an oculomotor syndrome including bilateral horizontal gaze paralysis affecting saccades and foveal pursuit. During full-field pursuit, oculocephalic movement, and after caloric stimulation, the right eye alone was able to move slowly only 30 degrees to the right of the midline. Convergence and vertical eye movements were unaffected in either eye. The lesion lay in the whole left pontine tegmentum and partly in the right pontine tegmentum which was also strongly compressed and displaced to the right. The bilateral horizontal gaze paralysis resulted from damage to both paramedian pontine reticular formations. The unusual combination of an absence of foveal pursuit with the persistence of a rightward full-field pursuit analysed in the light of recent experimental work, suggested a clear separation between the brainstem pathways of these two types of pursuit movement. Lastly, according to our data and other clinicopathological findings previously reported, it appeared also that the paramedian pontine reticular formation role in the triggering of voluntary vertical saccades is less significant in man than in the monkey.

[Cerebral and pulmonary histiocytosis X. Neurologic manifestations disclosing a pseudotumoral formation on the floor of the 4th ventricle]

The authors report a case of histiocytosis X which presented with neurological manifestations in a 20 year old man: episodes of headache with vomiting, followed, three months later, by the development of paralysis of the right 6th and 7th cranial nerves associated with nystagmus. The CT scan revealed a tumour-like lesion on the floor of the IVth ventricle with a long axis of 18 mm. The chest x-ray revealed diffuse nodular opacities in the pleural and apical regions with features suggestive of histiocytosis X. The diagnosis was confirmed by surgical biopsy of the typical pulmonary nodules which were rich in histiocytes with X bodies on electron microscopy. The neurological signs disappeared after one month of treatment with Prednisone (1 mg/kg/day) and Vincaleukoblastine (10 mg/week). By the 3rd month, the pulmonary lesions were reduced and the intra-ventricular formation had regressed by 40%. In the authors' series of 29 cases of confirmed histiocytosis X in adults, the present case is the only one with a clinical neurological presentation, apart from 3 cases of diabetes insipidus. A review of the literature confirms the rarity of this type of presentation. The suggestion of the diagnosis by the chest x-ray appearance enabled a dangerous neuro-surgical operation to be avoided.

Absence of functional messenger RNA for glycogen phosphorylase in the muscle of two patients with McArdle's disease

(1) Two unrelated cases of McArdle's disease (glycogen storage disease type V, deficiency in muscle-type glycogen phosphorylase, EC.2.4.1.1) with no detectable inactive protein, and two heterozygous relatives of one patient, have been investigated for the presence or absence of functional messenger RNA. Methods were developed and scaled down to be compatible with clinical-size biopsies. (2) Total muscle RNA was prepared and translated in a rabbit reticulocyte cell-free system. Neosynthesized products were isolated by immunoaffinity microchromatography. Phosphorylase was compared with control enzymes neosynthesized and purified under the same conditions. (3) No functional mRNA for phosphorylase could be detected in the muscles of the two patients. A decreased amount of messenger for phosphorylase, compared with the control enzymes, was found in the muscles of the two heterozygotes. (4) Exploration of functional messenger RNA in clinical enzymopathies should be readily adaptable to a number of enzymatic diseases.

[Chronic neurological syndrome resulting from intoxication with metallic uranium (author's transl)]

In 1972, a male patient, then 44-year-old, developed foot cramps and leg pain together with increasing gait disorders and a tendency to fall backwards. In 1976, an extrapyramidal syndrome with ataxia, nystagmus and peripheral neuropathy was discovered on neurological examination. The symptoms persisted and remained of obscure origin until 1979, when a detailed aetiological enquiry disclosed that during at least the first three years of his illness the patient had had on his desk a bar of metallic uranium which he frequently handled. Stool analysis showed significant uranium levels. In the absence of any other cause, it would appear that the neurological syndrome was due to intoxication with uranium. Although this had not been previously described in man, there are occasional reports of uranium toxicity in laboratory animals.

A new prognostic classification of chronic lymphocytic leukemia derived from a multivariate survival analysis

Survivals of two series of CLL patients (99 from a retrospective series and 196 from a prospective series) were studied separately. The three main staging systems (Rai, Binet, Rundles) agreed well, but as far as survival is concerned, too many stages are defined. The authors performed a Cox multivariate analysis of survival in order to isolate important prognostic factors at diagnosis and to use them to build a simple three-stage classification. Thrombopenia and anemia appeared as the most important risk factors. Among the nonanemic and nonthrombopenic patients, the number of involved areas was clearly related to prognosis in the authors' two series. This study allowed the authors to propose a new classification in three prognostic groups. Group C: anemia (Hb less than 10 g) and/or thrombopenia (platelets less than 100,000/mm3); about 15% of the patients; median of 2 years. Group B: no anemia, no thrombopenia, three or more involved areas (counting as one each of the following: axillary, cervical, inguinal, lymph nodes, whether unilateral or bilateral, spleen and liver); about 30% of patients; median of 7 years. Group A: no anemia, no thrombopenia, less than three involved areas; about 55% of patients; the survival of this group does not seem different from that of the French population of the same age and sex distribution. This three-stage classification only requires clinical examination and routine hemogram, has a good prognostic value which was confirmed on the series of Montserrat and Rozman (146 patients), and should therefore be helpful in planning new clinical trials.

[Rare etiology of hemiplegia with young adult: paradoxical embolism (author's transl)]

Paradoxical embolism is due to the passage of an embolic material from the deep veins of the lower extremities or pelvis, into the systemic circulation through an abnormal intracardiac communication. Only the angiographic and hemodynamic diagnosis practised on two young patients with a cerebral embolism, can explain the mechanism. The diagnosis is based on the arterial embolism, the venous thrombosis with or without pulmonary embolism, the abnormal communication favoring right-to-left shunting. The rising of right atrial pressures permits this shunting. This high pressure can result from a pulmonary embolism, a high blood pressue due to an effort, or an embolism that might coil up over the tricuspid valve.

The gene(s) controlling the synthesis of C1 esterase inhibitor is not linked to the genes of the HLA system and is not on the 6th chromosome

Certain genes of the complement system are carried by the 6th chromosome and are sometimes linked to particular genes of the HLA system. This study shows that in 15 patients suffering from hereditary angioneurotic oedema the gene(s) controlling the synthesis of C1 esterase inhibitor is not linked to the genes HLA-A or B and is not on the 6th chromosome.

[Neuropathy in long term treatment with metronidazole (author's transl)]

Two patients developed a sensory neuropathy while under treatment with Metronidazole for Crohn's disease. Recovery took place within a few months after drug withdrawal but was still incomplete in one patient one year after cessation of Metronidazole intake. The incidence of neuropathy appears to be high in long term use of this drug. The morphological study of a sural nerve biopsy showed a severe loss of myelinated fibers (1 800 par mm2). Quantitative teased fibers preparation showed that 56 per cent of the fibers were undergoing wallerian degenerations ; segmental demyelination with subsequent remyelination was found in 4 per cent of the fibers and seem to be secondary to axonal involvement.

[Hodgkin's disease: study of delayed hypersensitivity of 64 non treated patients. Value of epicutaneous test using croton oil]

Cellular immunity in 64 patients with Hodgkin's disease was studied during diagnosis before any treatment. The functional deficiency of the thymodependent lymphocyte was demonstrated in vivo by skin tests and, in vitro, by the test of inhibition of leucocyte migration to phytohemagglutininin and spontaneous rosette formation, to sheep red cells. This deficiency correlates with the clinical spread and the histological severity. The relationship between skin anergy and biological tests was found. The epicutaneous test using croton oil possesses non-specific inflammatory activity. It is negative this test is negative, skin reactivity to specific antigens is reduced. The croton tests help interpretation of skin responses to specific antigens and thus assessment of the immune state.

[T.R.H. test in 93 cases of thyroid disease]

The authors used the stimulation of TSH test by intravenous injection of TRH in 93 patients. They obtained a negative or weak response in thyrotoxicosis, toxic adenomas, and Means syndrome, and a normal response with non-extinctive hot nodules. The response was positive and high in primary hypothyroidism. The results are sometimes paradoxal in hypothalamo-pituitary pathology even after hypophysectomy: a delayed and elevated response is in favour of a pituitary reserve of non-utilised TSH. In non-functional goitres and thyroiditis, the sometimes positive responses obtained are an indication for substitutive and depressive therapy.