Clinical outcome following B cell depletion therapy in eight patients with refractory idiopathic inflammatory myopathy

OBJECTIVE

To assess the efficacy of B lymphocyte depletion therapy (BCDT) in patients with refractive idiopathic inflammatory myopathy (IIM).

METHODS

Eight patients thought to have IIM were treated with BCDT utilising rituximab. Five were treated as part of an open label trial and three on the basis of perceived clinical need. Rituximab (1 gram) and methylprednisolone (100 mg) were given as intravenous infusions on days 0 and 14. The primary efficacy outcome at 6 months was 15% improvement in muscle strength and 30% reduction in CPK.

RESULTS

Two patients with Jo-1 antibody positive dermatomyositis (DM) demonstrated a clinical response. Both achieved >30% improvement in CPK. In one, the CPK remained within the normal range for 10 months, the other had a normalised CPK and stabilisation of lung function tests for 36 months. Muscle strength by myometry, however, did not achieve the primary outcome, although, patient 1, demonstrated an improvement of 20% at 8 months (the patient had elective surgery of the hand during the study period). Jo-1 antibody levels fell modestly in both patients but remained detectable. Re-evaluation of three patients revealed that one had inclusion body myositis, one had sporadic muscular dystrophy and one subsequently developed nodular sclerosing lymphoma. All except one patient showed adequate B cell depletion with re-population occurring 3- >42 months after BCDT. One patient did not deplete and died of an unrelated cause.

CONCLUSIONS

This study emphasizes the importance of identifying and selecting the appropriate sub-group of patients with IIM most likely to respond to BCDT.

Isoflurane and Propofol Have Similar Effects on Spinal Neuronal Windup at Concentrations that Block Movement

BACKGROUND

We investigated the actions of isoflurane and propofol on neuronal windup in the spinal cord of intact rats. We hypothesized that propofol would depress windup more than isoflurane.

METHODS

In a cross-over design, rats received 0.8 and 1.2 minimum alveolar concentration (MAC) isoflurane and 0.8 and 1.2 ED50 (effective dose(50%)) of propofol, as recordings were made from single units in the lumbar cord (n = 13). Electrical stimuli were applied (20 stimuli at 0.1, 1, and 3 Hz). Neuronal responses were analyzed for those occurring in the C-fiber range (100-400 ms after each stimulus), combined C-fiber and afterdischarge range (100-1000 ms) and the 100-333 ms range for the 3 Hz stimuli. Absolute windup was also calculated (the sum of action potentials for 20 stimuli - 20 x response to the first stimulus).

RESULTS

At 1 Hz, total action potentials (mean, standard error) summed across the 20 stimuli (100-1000 ms range) were 571 +/- 106 and 742 +/- 214 for isoflurane (at 0.8 and 1.2 MAC) and 586 +/- 148 and 641 +/- 143 for propofol (at 0.8 and 1.2 ED50), respectively (P = NS); corresponding values for the 0.1 Hz stimuli were 345 +/- 104, 370 +/- 108, 430 +/- 86, and 403 +/- 106 (P = NS), and for the 3 Hz stimuli (100-333 ms range) were 266 +/- 66, 333 +/- 76, 343 +/- 85, and 252 +/- 72 (P = NS). Absolute windup in the 100-1000 ms range was greater for 1.2 MAC isoflurane at 1 Hz (445 +/- 82, P < 0.01), when compared with absolute windup at 0.8 MAC isoflurane and 0.8 and 1.2 ED50 propofol (232 +/- 31, 88 +/- 65, and 210 +/- 41, respectively).

CONCLUSIONS

These data suggest that isoflurane and propofol have similar effects on neuronal windup in the spinal cord, although there was enhanced absolute windup at 1.2 MAC isoflurane for the 1 Hz stimulus.

Candida rugosa, an emerging fungal pathogen with resistance to azoles: geographic and temporal trends from the ARTEMIS DISK antifungal surveillance program

Candida rugosa is a fungus that appears to be emerging as a cause of infection in some geographic regions. We utilized the extensive database of the ARTEMIS DISK Antifungal Surveillance Program to describe the geographic and temporal trends in the isolation of C. rugosa from clinical specimens and the in vitro susceptibilities of 452 isolates to fluconazole and voriconazole. C. rugosa accounted for 0.4% of 134,715 isolates of Candida, and the frequency of isolation increased from 0.03% to 0.4% over the 6.5-year study period (1997 to 2003). C. rugosa was most common in the Latin American region (2.7% versus 0.1 to 0.4%). Decreased susceptibility to fluconazole (40.5% susceptible) was observed in all geographic regions; however, isolates from Europe and North America were much more susceptible (97 to 100%) to voriconazole than those from other geographic regions (55.8 to 58.8%). C. rugosa was most often isolated from blood and urine in patients hospitalized at the Medical and Surgical inpatient services. Notably, bloodstream isolates were the least susceptible to both fluconazole and voriconazole. C. rugosa should be considered, along with the established pathogens Candida krusei and Candida glabrata, as a species of Candida with reduced susceptibility to the azole antifungal agents.

In vitro susceptibilities of Malaysian clinical isolates of Cryptococcus neoformans var. grubii and Cryptococcus gattii to five antifungal drugs

The in vitro susceptibilities of Malaysian clinical isolates of Cryptococcus neoformans var. grubii and C . gattii to five antifungal drugs (amphotericin B, flucytosine, fluconazole, itraconazole and ketoconazole) were determined using the Etest method. None of the Malaysian isolates was resistant to amphotericin B and ketoconazole. Isolates resistant to flucytosine, fluconazole and itraconazole were observed in this study. Minimum inhibition concentrations (MICs) of > or = 32 microg ml(-1) against flucytosine, > or = 64 microg ml(-1) against fluconazole and > or = 1 microg ml(-1) against itraconazole were noted in four (8.3%), two (4.2%) and one (2.1%) isolates respectively. There was no significant difference in the MICs for both Cryptococcus species (P > 0.05), indicating that C. gattii was as susceptible as var. grubii to all the antifungal drugs tested. No significant difference in the MICs for both Cryptococcus species collected from 1980 to 1990 and 2002 to 2004 were observed (P > 0.05).

Molecular subtyping of clinical isolates of Candida albicans and identification of Candida dubliniensis Malaysia

The genotypes of 221 recent isolates of Candida albicans from various clinical specimens of 213 patients admitted to the University Malaya Medical Centre, Malaysia was determined based on the amplification of a transposable intron region in the 25 S rRNA gene. The analyses of 178 C. albicans isolated from nonsterile clinical specimens showed that they could be classified into three genotypes: genotype A (138 isolates), genotype B (38 isolates) and genotype C (2 isolates). The genotyping of 43 clinical isolates from sterile specimens showed that they belonged to genotype A (29 isolates), genotype B (10 isolates), genotype C (2 isolates) and genotype D (2 isolates). The overall distribution of C. albicans genotypes in sterile and nonsterile specimens appeared similar, with genotype A being the most predominant type. This study reported the identification of C. dubliniensis (genotype D) in 2 HIV-negative patients with systemic candidiasis, which were missed by the routine mycological procedure. The study demonstrated the genetic diversity of clinical isolates of C. albicans in Malaysia.

Association of antinucleosome antibodies with disease flare in serologically active clinically quiescent patients with systemic lupus erythematosus

OBJECTIVE

To identify the prevalence of serologically active clinically quiescent (SACQ) patients in a cohort of 290 patients with systemic lupus erythematosus (SLE). We investigated if the presence of anti-double-stranded DNA (anti-dsDNA) or antinucleosome (anti-NCS) antibodies during the SACQ period was associated with future flares.

METHODS

SACQ patients defined as clinically inactive for 6 months (global British Isles Lupus Activity Group index [BILAG] scores <6) and serologically active (anti-dsDNA antibodies >50 units/ml on at least 2 occasions by enzyme-linked immunosorbent assay [ELISA]) were identified. Patient sera collected during the defined SACQ period were also tested for anti-NCS antibodies (ELISA). We retrospectively reviewed patient clinical details and episodes of flare using the BILAG activity index.

RESULTS

Twenty-seven (9%) patients were SACQ. Seventeen (81%) patients experienced a flare (total of 91 flares, up to 12 flares per person) in the next 5 years. Median duration to first flare was 15 months (range 2-46). Time to first flare after SACQ period was significantly correlated with the presence of anti-NCS (P = 0.0012), high anti-NCS antibody titers (P = 0.0006), and anti-dsDNA titers 5 times above the normal limit (P = 0.02). Patients with higher absolute anti-NCS antibody titers showed a significant correlation with the number of flares (r = 0.57, P = 0.007).

CONCLUSION

A minority of patients with SLE are SACQ. The majority of these patients experience a flare in the next 5 years and close followup is recommended. Anti-NCS antibodies may be a better predictor than anti-dsDNA antibodies for future flares.

Oral candidal species among smokers and non-smokers

OBJECTIVE

To determine the various oral Candidal species among healthy Malaysian adults.

DESIGN

Case-control study.

PLACE AND DURATION OF STUDY

This study was collaborated between the Department of Medical Microbiology, Faculty of Medicine and Department of Oral Pathology, Oral Medicine and Periodontology, Faculty of Dentistry, University of Malaya, Kuala Lumpur, Malaysia, between September 2002 till January 2004.

PATIENTS AND METHODS

One hundred adults (50 smokers and 50 non-smokers), aged between 40 and 70 years were studied. Swabs and carbohydrate assimilation (Saboraud Dextrose Agar, Corn Meal Agar, API 20C AUX System) were performed. Specimens were collected from dorsum of the tongue, buccal mucosa and commissures (right and left each). Colony forms were established by positive colony forming units, on SDA medium (24-48 hours). Germ tube test for (true/pseudohyphae) growth was done on Corn Meal Agar Medium. Candida biotypes were evaluated by API 20C AUX system, which had a numerical 7 digit profile, added to evaluate a definite Candida species.

RESULTS

Thirty-five percent of Malaysian adults harbored Candida intraorally. Candidal species identified among 100 subjects had C. albicans (27) 77%, C. glabrata (3) 8%, C. famata, C. tropicalis, C. krusei, C. lusitaniae and C. guilliermondii (1) 3% each. Thirty-three positive cases comprised of 35 species i.e. two cases had two species each. Fifty seven percent of these were smokers and 43% non-smokers. These included 40% Chinese, 36% Malays and 24% Indians. Species were, however, not specified according to intra-oral sites i.e. buccal, commissural mucosa and dorsum of tongue.

CONCLUSION

On this series C. albicans is the most common species found in the oral cavity of Malaysian adults. It is equally frequent in smokers and non-smokers, but showed a predilection for the ethnic Chinese group.

Repeated B cell depletion in treatment of refractory systemic lupus erythematosus

OBJECTIVES

To report the clinical outcome and safety profile of repeated B cell depletion in seven patients with refractory systemic lupus erythematosus (SLE).

METHODS

Since June 2000, seven patients with refractory SLE had repeated cycles of B cell depletion (18 cycles in total, up to three cycles per patient) because of disease relapse. The clinical response (assessed by the British Isles Lupus Activity Guide (BILAG) activity index), duration of B cell depletion, and adverse events in these patients was reviewed.

RESULTS

Four patients (Nos 1, 2, 3, 6) had three cycles of treatment and three (Nos 4, 5, 7) had two cycles. Four of the seven patients (Nos 1, 3, 5, 6) improved. The mean global BILAG scores dropped from 15 to 6 at 5-7 months. The median duration of clinical response and B cell depletion was 13 months and 6 months, respectively. After the third cycle, 2/4 patients (Nos 1 and 2) improved. The median duration of clinical benefit was 12 months. Most patients tolerate re-treatment very well.

CONCLUSION

Re-treatment with B cell depletion of patients with severe SLE is safe and may be effective for 6-12 months on average.

The mycological and molecular study of Hortaea werneckii isolated from blood and splenic abscess

Hortaea werneckii is an environmental dematiaceous fungus found in the halophilic environment. It causes tinea nigra. We report the isolation of H. werneckii from blood and splenic abscess of two patients with acute myelomonocytic leukaemia. H. werneckii grew at room temperature but not at 37 degrees C, it was identified by biochemical tests, growth characteristics and the presence of conspicuous collarette intercalary on dividing yeast cells. The use of specific oligonucleotide primer Hor-F (5'-TGGACACCTTCA TAACTCTTG-3') and Hor-R (5'-TCACAACGCTTAGAGACGG-3') confirmed the two isolates were H. werneckii. The sequence for 281 nucleotide of HW299 and HW403 were 99% identical but differed only in one nucleotide. In vitro anti-fungal susceptibility testing showed that the isolates were resistant to amphotericin B and flucytosine.

Impact of the Expanded Program of Immunization against hepatitis B infection in school children in Malaysia

The implementation of the Expanded Program of Immunization (EPI) in 1989 has dramatic impact on hepatitis B virus (HBV) infection in school children in Malaysia. A cross-sectional seroprevalence study of HBV infection in 190,077 school children aged 7-12 years from 1997 to 2003 showed a steady decline of HBV surface antigen (HBsAg) prevalence rate from 2.5% for children born in 1985 to 0.4% among school children born in 1996. The overall prevalence of HBsAg was 0.6%, 0.7% in males and 0.6% in females. Over 92.7% of school children had been vaccinated with HBV vaccine, in which 93.7% were vaccinated under the EPI and 6.3% on voluntary basis. The school children vaccinated under EPI had a 0.4% HBsAg carrier rate, which was significantly lower than school children vaccinated on a voluntary basis (HBsAg carrier rate 1.3%) and non-vaccinated school children (HBsAg carrier rate 2.7%), suggesting that HBV vaccination of infants was the most effective measure in preventing vertical transmission of HBV in the hyperendemic region.

Salmonellosis in persons infected with human immunodeficiency virus: a report of seven cases from Malaysia

Persons infected with human immunodeficiency virus (HIV) have an increased risk of salmonellosis when compared to the general population. We describe seven such patients with Salmonella bacteremia, of whom two had recurrent salmonellosis. In the latter two cases the infection was unusually severe, characterized by widespread infection, bacteremia and relapse, despite standard antimicrobial therapy. HIV-infected individuals will benefit from education on the source of Salmonella, mode of acquisition and prevention through safe food handling and food preparation practices. Because of the difficulty of eradicating Salmonella infection in patients with acquired immunodeficiency syndrome, long-term suppressive treatment with antimicrobials is warranted.

An outbreak of acute haemorrhagic conjunctivitis in Melaka, Malaysia

This paper reports a second outbreak of acute haemorrhagic conjunctivitis due to coxsackievirus A24 in peninsular Malaysia. Between June 2002 and early October 2003, 10,327 patients, comprising 3,261 children and 7,066 adults, were treated for acute conjunctivitis in 11 government health clinics in the Melaka Tengah district of the state of Melaka. The figure grossly underestimates the size of the outbreak; as no patients treated in private clinics in the same district were included. Institution and household surveillance showed that the commonest presenting clinical feature of the illness was eye-discharge (91.2%), followed by foreign body sensation (81.8%), pain (78.3%) and subconjunctival haemorrhage (74.4%). The mean duration of illness was 6.5 and five days for patients with and without subconjunctival haemorrhage respectively.

Scopulariopsis brevicaulis infection in a patient with acute myeloid leukemia

Scopulariopsis brevicaulis is a soil fungus normally associated with onychomycosis. It causes subcutaneous infection in immunocompromised patients and is rarely isolated from blood. A case of systemic Scopulariopsis brevicaulis infection was reported in a patient with acute myeloid leukemia. The patient developed persistent fever that did not respond to wide spectrum antibiotics and amphotericin B. Scopulariopsis brevicaulis was the only pathogen isolated from blood cultures. The fever subsided with itraconazole and there was no recurrence of fungal infection with prolonged maintenance of oral itraconazole.

Evaluation of three commercial rapid tests for detecting antibodies to human immunodeficiency virus

Determine HIV-1/2, Chembio HIV-1/2 STAT-PAK and PenTest are simple/rapid tests for the detection of antibodies to HIV-1 and HIV-2 in human whole blood, serum and plasma samples. The assay is one step and the result is read visually within 15 minutes. Using 92 known HIV-1 reactive sera and 108 known HIV-1 negative sera, the 3 HIV tests correctly identified all the known HIV-1 reactive and negative samples. The results indicated that Determine HIV-1/2, Chembio HIV-1/2 STAT-PAK and PenTest HIV are as sensitive and specific (100% concordance) as Microparticle Enzyme Immunoassay. The data indicated that these 3 HIV tests are effective testing systems for diagnosis of HIV infection in a situation when the conventional Enzyme Immunoassay is not suitable.

Dermatophytes isolated from patients in University Hospital, Kuala Lumpur, Malaysia

A total of 576 dermatophytes were isolated from patients with a variety of skin infections from January 1993 to May 2000. Ten species of dermatophytes were identified: Epidermophyton floccosum (0.7%), Microsporum audouinii (1.1%), M. canis (3.1%), M. gypseum (0.3%), Trichophyton concentricum (3.5%), T. equinum (0.2%), T. mentagrophytes (36.1%), T. rubrum (53.8%), T. verrucosum (0.2) and T. violaceum (1.0%). The body sites most frequently affected by dermatophytes were the buttocks, nails and trunk. Anthropophilic dermatophytes made up 60.1% of the isolates; the most common species was T. rubrum, T. mentagrophytes and M. canis were the two main zoophilic dermatophytes. T. mentagrophytes was isolated from all body sites except the scalp. M. canis was found to be associated with domestic dogs and was not isolated from ethnic Malays. The only geophilic dermatophyte was M. gypseum, an uncommon dermatophyte associated with tinea pedis.

Retrospective review of spinal versus epidural anaesthesia for caesarean section in preeclamptic patients

A 5-year retrospective survey of anaesthesia for caesarean section for mild/moderate and severe preeclampsia was performed, covering the period between 1 January 1996 and 31 December 2000. One hundred and twenty-one cases of non-labouring preeclamptic patients receiving spinal or epidural anaesthesia for caesarean section were included for analysis. Comparisons were made of the lowest blood pressures recorded before induction of anaesthesia, during the period from induction to delivery and the period from delivery to the end of operation. The decreases in blood pressure were similar after spinal and epidural anaesthesia. The use of intravenous fluids and ephedrine were also comparable in the two anaesthetic groups. There was no difference in maternal or neonatal outcome. Our result supports the use of spinal anaesthesia in preeclamptic women.

Trends in obstetric anaesthesia and analgesia over a ten year period in the University Malaya Medical Centre, Kuala Lumpur

Available data for obstetric care in the University Malaya Medical Centre, Kuala Lumpur from 1987 to 1999 were reviewed. Despite incomplete data, we were able to determine fairly well the practice of obstetric anaesthesia and analgesia in the unit, and the changes over the years. There was a decline in the use of general anaesthesia for both elective and emergency caesarean sections from 41.3% and 69.4% respectively in 1995 to 21.6% and 26.9% respectively in 1999. By 1999, regional anaesthesia had become the most common method of anaesthesia administered in both elective (14.3% epidural and 63.5% spinal) and emergency (30.2% epidural and 42.6% spinal) caesarean sections. The percentage of patients delivering vaginally who received epidural analgesia appeared to have stabilised at about 8 to 9% in the last few years, with a gradual decline in the total instrumental delivery rate from a high of about 12% to the pre-epidural rate of 7%.

Non-sporulating Chrysosporium: an opportunistic fungal infection in a neutropenic patient

We report a case of an invasive infection with non-sporulating Chrysosporium species in a patient who was treated with chemotherapy for relapsed acute lymphoblastic leukemia. This patient presented with a persistent lobar pneumonia, skin lesions, and possible involvement of the central nervous system. The patient responded to treatment with amphotericin B and oral itraconazole.

Systemic Candida infection in University hospital 1997-1999: the distribution of Candida biotypes and antifungal susceptibility patterns

A total of 102 Candida species were isolated from blood cultures from January 1997 to October 1999. Using assimilation of carbohydrate test, 52 (51.0%) of the Candida sp. were identified as C. parapsilosis, 25.5% (26) were C. tropicalis. C. albicans made up 11.8% (12), 6.9% (7) were C. rugosa, 3.8% (4) C. glabrata and 1% (1) C. guilliermondii. No C. dubliniensis was found in the study. In vitro antifungal susceptibility tests showed that all Candida species were sensitive to nystatin, amphotericin B and ketoconazole. Although all isolates remained sensitive to fluconazole, intermediate susceptibility was found in 3 C. rugosa isolates. Antifungal agents with high frequency of resistance were econazole, clotrimazole, miconazole and 5-fluorocytosine. Candida species found to have resistance to these antifungal agents were non-C. albicans.

Fire during thoracic surgery

A 67-year-old male with bilateral lung lesions presented for median sternotomy. One-lung ventilation was complicated by arterial desaturation. Continuous positive airway pressure with oxygen was applied to the non-ventilated lung to relieve the hypoxaemia. However, the cotton gauze packed inside the operative site was ignited by the electrocautery. The burning gauze was immediately removed without any complication. We report a case of electrocautery-induced fire during thoracic surgery done in supine position and discuss its implication on the choice of oxygen enrichment therapy during one-lung ventilation.

Effects of estrogens in vitro and in vivo on cartilage growth in the tilapia (Oreochromis mossambicus)

To study the effects of estrogens on cartilage growth in the tilapia Oreochromis mossambicus, an epiceratobranchial cartilage radioisotope incorporation assay was employed to measure proteoglycan synthesis and prechondrocyte proliferation by incorporation of radiolabeled sulfate and thymidine, respectively. Cartilage explants were cultured with estrogens with or without recombinant bovine insulin-like growth factor-I (IGF-I). In vitro experiments using the natural teleost estrogen, 17beta-estradiol (E2), showed a trend toward inhibition of sulfate incorporation and an inhibition of thymidine incorporation at higher doses (10 micrograms/ml), but not at physiological levels. E2 also showed a trend toward inhibition of sulfate and thymidine incorporation in the presence of IGF-I. Similar results were found with other estrogenic compounds in vitro: ethinylestradiol, diethylstilbestrol (DES), genistein, and nonylphenol. Ethinylestradiol inhibited sulfate and thymidine incorporation at 1000 ng/ml in the presence of IGF-I. DES inhibited thymidine incorporation at 1000 ng/ml in untreated or IGF-I-exposed cartilage. Genistein inhibited sulfate incorporation at 100 micrograms/ml in IGF-I-exposed cartilage and inhibited thymidine uptake at 1, 10, and 100 micrograms/ml in untreated and IGF-I-exposed cartilage. Nonylphenol inhibited sulfate uptake at 100 microM in untreated and IGF-I-exposed cartilage. Nonylphenol alone at 10 and 100 microM inhibited thymidine uptake. In IGF-I-exposed cartilage nonylphenol inhibited thymidine uptake at 100 microM. Fish receiving estrogen injections (E2 or DES) in vivo at a concentration of 2 micrograms/g body weight showed increased sulfate incorporation by cartilage in vitro. Stimulation in vivo by estrogens, in contrast to the inhibition by high doses in vitro, may be a result of the influence of estrogen on pituitary growth hormone release.