Electroencephalographic mapping and 99mTc HMPAO single-photon emission computed tomography in carbon monoxide poisoning

STUDY OBJECTIVE

To investigate whether topographic analysis of EEG mapping and technetium-99m (99mTc) hexamethylpropylenamine oxide (HMPAO) brain single-photon emission computed tomography (SPECT) can detect cerebral anomalies in the acute phase of carbon monoxide poisoning.

DESIGN

Twelve patients aged 18 to 55 years with severe carbon monoxide poisoning and no history of neurologic disorder were evaluated. Either nasal (5 patients) or hyperbaric (7 patients) oxygen therapy was administered. Criteria for hyperbaric oxygen therapy were blood CO of more than 20%, loss of consciousness, pregnancy, or signs of cardiac injury. After oxygen treatment, all patients had a blood CO value of 0% and no patient had persistent acute signs of toxicity. Patients then were investigated by confentional EEG, EEG mapping, and 99mTc HMPAO brain SPECT. These procedures were performed on the day of admission.

PARTICIPANTS

After nasal (5 patients) or hyperbaric (7 patients) oxygen therapy was administered, 12 adults with severe carbon monoxide poisoning were evaluated. All studies were performed on the day of admission.

MEASUREMENTS

Conventional EEG, EEG mapping, and 99mTc HMPAO brain SPECT.

RESULTS

While classic EEG was normal in 9 of 12 patients and showed diffuse anomalies in 3, EEG mapping and 99mTc HMPAO brain SPECT demonstrated unilateral or bilateral regional anomalies in 8 of 12 patients. Anomalies were localized in temporo-parieto-occipital areas, the watershed areas of the major cerebral arteries, or in temporal cortex.

CONCLUSION

These preliminary results suggest that EEG mapping and 99mTc HMPAO brain SPECT can be complementary tools to diagnose early regional cerebral anomalies in carbon monoxide-poisoned patients.

Primary systemic amyloidosis: a rare complication of immunoglobulin M monoclonal gammopathies and Waldenström's macroglobulinemia

PURPOSE

To determine the natural history of amyloidosis associated with Waldenström's macroglobulinemia and immunoglobulin M (IgM) monoclonal gammopathy.

PATIENTS AND METHODS

From January 1968 to September 1990, 50 patients with a serum IgM monoclonal protein and biopsy-proven amyloidosis were evaluated at the Mayo Clinic. There were 32 men and 18 women (age range, 43 to 93 years).

RESULTS

Percentages of patients presenting with cardiac, renal, hepatic, and pulmonary amyloid were 44%, 32%, 14%, and 10%, respectively. Forty-two percent of the patients had an M protein value greater than 1.5 g/dL, and 12% had an M component greater than 3 g/dL. Subcutaneous fat, rectum, and bone marrow showed amyloid in 84%, 72%, and 50%, respectively, providing a simple technique for diagnosing amyloidosis. The bone marrow biopsy was consistent with Waldenström's macroglobulinemia in 10, a plasma-cell proliferative disorder in 10, and lymphoma or a lymphoproliferative disorder in 11; results were normal, nondiagnostic, or hypercellular in 17. Forty-three of 50 patients died. The median survival of the entire group was 24.6 months. Fifty-three percent of deaths were due to cardiac amyloid, 12% to respiratory failure, 7% to macroglobulinemia, 7% to liver failure, and 7% to kidney failure.

CONCLUSION

The presence of amyloid cardiomyopathy and an increased creatinine concentration at diagnosis had an adverse impact on survival. Of the 22 patients who presented with cardiomyopathy, the median survival was 11.1 months, with only two surviving longer than 5 years. The median survival of the 28 patients without cardiomyopathy at diagnosis was 27 months, with eight 5-year survivors (P = .013). All eight amyloid deposits studied stained for Ig light chain, indicating that this amyloidosis is of the primary (AL) type.

The 5q- syndrome: a single-institution study of 43 consecutive patients

A favorable prognosis and a low rate of leukemic transformation has been attributed to the 5q- syndrome, a myelodysplastic syndrome (MDS) characterized by macrocytic anemia, hypolobulated micromegakaryocytic hyperplasia, and an interstitial deletion of chromosome 5. We examined the characteristics and outcome of 43 consecutive patients in our institution strictly defined by morphologic criteria and a solitary 5q- cytogenetic defect. The median age at diagnosis was 68 years, with a clear female predominance (7:3). Eighty percent of the patients were red blood cell transfusion-dependent at diagnosis and all untransfused patients had macrocytic indexes. In contrast, significant neutropenia or thrombocytopenia was rare. The French-American-British (FAB) class distributions were RA (72%), RARS (7%), RAEB (16%), and RAEB-IT (5%). At a median follow-up of 31 months, 56% of the patients survive, with a projected median survival of 63 months. The incidence of acute leukemia was 16% and was uniformly fatal. Clinical hemosiderosis occurred in 28% of the patients, resulting in two deaths. Neither survival nor the risk of leukemic transformation was predictable from initial clinical parameters, including FAB classification, Bournemouth score, and degree of aneuploidy. The lack of significant neutropenia and thrombocytopenia seemed to account for a very low incidence of infection and bleeding resulting in a prognosis equal or superior to historical patients with MDS. Therapeutic endeavors, including the use of corticosteroids, androgens, cis-retinoic acid, pyridoxine, and danazol, were largely unsuccessful.

Refractory thrombocytopenia. A myelodysplastic syndrome that may mimic immune thrombocytopenic purpura

The French-American-British classification scheme of myelodysplastic syndromes includes a category of refractory cytopenia that includes refractory thrombocytopenia (RTC). Because dysmegakaryopoiesis manifesting as an isolated cytopenia can be difficult to identify morphologically and because it may be accompanied by megakaryocytic hyperplasia, RTC may be confused with idiopathic thrombocytopenic purpura. A review of 1,220 cases of myelodysplastic syndromes at Mayo Clinic Jacksonville and Mayo Clinic Rochester from 1979 to 1990 yielded 9 cases (0.7%) of isolated thrombocytopenia (RTC) associated with clonal chromosome abnormalities. Review of 319 marrow chromosome analyses performed at the cytogenetics laboratory at Mayo Clinic Rochester from 1979 to 1990 for patients with low platelet count yielded two additional cases of RTC (0.6%). Of the 11 RTC cases, 3 previously had been misdiagnosed as idiopathic thrombocytopenic purpura. All patients had oval macrocytes in peripheral blood smears and abnormal megakaryocyte morphology in bone marrow aspirates, lacked antiplatelet antibodies, and did not have splenomegaly on clinical examination. The most common clonal chromosome abnormalities involved chromosomes 3, 5, 8, or 20. Steroid therapy was ineffective. Clinical and laboratory findings can establish the diagnosis of RTC and allow the physician to avoid recommending inappropriate therapy (steroids or splenectomy) for these patients.

Atrial fibrillation as a risk factor for deep venous thrombosis and pulmonary emboli in stroke patients

In 539 consecutive stroke patients admitted to a rehabilitation department, we studied the possible role of atrial fibrillation as a risk factor for deep venous thrombosis and pulmonary embolism by analyzing a series of relevant clinical data in patients with and without atrial fibrillation and in patients with and without venous thromboembolic complications. Deep venous thrombosis as well as advanced age and cardiac disease were significantly (p less than 0.001) more frequent in patients with atrial fibrillation. However, in a model of simultaneous logistic regression carried out on the presence of absence of venous thromboembolic complications, atrial fibrillation was the only significant risk factor. In view of the morbidity and mortality linked to deep venous thrombosis, our findings argue for preventive anticoagulation therapy in stroke patients suffering from atrial fibrillation and merit further study.

Differential expression of isopeptide bonds N epsilon (gamma-glutamyl) lysine in benign and malignant human breast lesions: an immunohistochemical study

N epsilon (gamma-glutamyl) lysine isopeptide bonds were detected in situ in histological sections from benign and malignant human breast tissue using the monoclonal antibody (MAb) 81D1c2. On cryostat sections of fresh-frozen mammary tissue post-fixed in acetone, or on paraffin sections also from mammary tissue fixed in Bouin's solution, the MAb reacted preferentially with glandular epithelial cells and staining was restricted to the nuclei. In 41 out of 44 benign lesions examined, staining was strong or moderate, while in 25 out of 33 malignant lesions no staining was observed. In the 8 remaining lesions of this group, staining was positive but weak. The difference in reactivity of this MAb with the 2 types of lesions is highly significant (p less than 0.0005) according to the chi 2 test.

Cerebral palsy: initial experience with Tc-99m HMPAO SPECT of the brain

The outlook for children with cerebral palsy is determined by the severity of motor problems and the presence of associated disabilities, in which early detection remains a medical challenge. The authors studied 13 children (aged 13 months to 12 years) with cerebral palsy by means of single photon emission computed tomography (SPECT) of the brain with technetium-99m hexamethylpropyleneamineoxime (HMPAO). In all children with hemiplegia, SPECT demonstrated hypoperfusion in the hemisphere contralateral to the motor deficit. SPECT demonstrated normal findings in patients with mild diplegia; bilateral hypoperfusion in the superior motor cortex in patients with moderate di- or tetraplegia; and bilateral reduction of perfusion in the superior motor, inferior motor, prefrontal, and parietal cortices in patients with severe di- or tetraplegia. Results suggest that Tc-99m HMPAO SPECT of the brain is a valuable complementary tool for thorough neurologic assessment in cerebral palsy.

Pentoxifylline inhibits lipopolysaccharide-induced serum tumor necrosis factor and mortality

Tumor necrosis factor, a mononuclear phagocyte-derived peptide produced in response to lipopolysaccharide, has been shown to mediate certain aspects of septic shock and multiple organ failure resulting from gram-negative septicemia. In the present investigation, pretreatment of animals with pentoxifylline inhibited lipopolysaccharide-induced serum tumor necrosis factor in a dose-dependent fashion. Pentoxifylline prevented the sequestration of neutrophils seen in animals given intravenous lipopolysaccharide. Furthermore, pentoxifylline protected animals from the lethal effects of an intravenous challenge with lipopolysaccharide. These data indicate that pentoxifylline inhibits lipopolysaccharide-induced tumor necrosis factor and may be an effective agent in mitigating the lethal consequences of sepsis and other disease processes mediated by this cytokine.

Phase I clinical trial with carbetimer

Carbetimer, a low molecular weight polymer derived from ethylene and maleic anhydride, belongs to a class of chemical compounds different from previously available anticancer agents. It has shown moderate antitumor activity against the Madison 109, Lewis lung, colon 26 and M5076 ovarian carcinomas. In the human tumor stem cell assay, antitumor activity was seen against carcinomas of the breast, ovary, lung, colon and kidney. A total of 26 patients with solid tumors were entered into this trial; carbetimer was given on 5 consecutive days as a 1-2-h intravenous infusion. The dose was escalated from 1.08 to 11 g/m2/day. The drug did not induce the usual side-effects of chemotherapy: leukopenia, thrombocytopenia, alopecia and mucositis were minimal or totally absent. Gastrointestinal toxicity was limited to mild to moderate nausea and vomiting; these were observed at all dose levels and required antimetics in only two patients. The major side-effects of carbetimer consisted of hypercalcemia and neurotoxicity. Hypercalcemia was dose- and treatment duration-dependent. The precise mechanism of hypercalcemia is presently under investigation, but remains unclear. Neurotoxicity was observed only after prolonged therapy; two patients, who received cumulative doses higher than 250 g/m2, developed a peripheral neuropathy with paresthesia, decrease in sensory perception and motor weakness. One patient recovered completely; the other patient improved slightly before developing fatal brain metastases. Two patients with malignant melanoma exhibited major antitumor response; both were previously treated; after excellent partial responses to carbetimer, both were operated on and one is presently disease-free 2 1/2 years after completion of therapy with carbetimer. In conclusion, carbetimer is a new compound with an unusual pattern of side-effects and interesting antitumor activity against malignant melanoma. Its antitumor activity is presently being investigated in phase II trials.

Plasma cell leukemia: an evaluation of response to therapy

Forty-three patients with plasma cell leukemia were seen at the Mayo Clinic. Twenty-five (58 percent) had primary plasma cell leukemia (diagnosis first made in the leukemic phase) and 18 (42 percent) had secondary plasma cell leukemia (leukemic transformation of a previously diagnosed multiple myeloma). Patients with secondary plasma cell leukemia were older, had a greater incidence of lytic bone lesions, had a lower platelet count, and had a larger M-protein in the serum than did patients with primary plasma cell leukemia. The median survival was 6.8 months for patients with primary plasma cell leukemia and 1.3 months for patients with secondary plasma cell leukemia. In patients with primary plasma cell leukemia, multiple alkylating agents produced a higher response rate than did melphalan, but the median time from treatment to progression or death was not significantly improved with such therapy. Review of the literature also suggests that the response rate is higher with combination chemotherapy than with single alkylating agents. Patients with secondary plasma cell leukemia usually show resistance to any type of chemotherapy and have a short survival.

Unusual cause of cerebellar abscess: occipital dermal sinus and dermoid cyst

Cerebellar abscess induced by a contiguous dermal sinus is a rare event. In a large series of acute posterior fossa abscedation, otogenic suppuration is the cause in 93% of the cases, while hematogenous infection is infrequent, probably because of the relatively weak bloodflow in this part of the central nervous system. The authors present an occipital dermal sinus and dermoid cyst revealed by a cerebellar abscess. The literature is reviewed briefly, treatment and prophylactic measures are discussed.

Monoclonal proteins in chronic lymphocytic leukemia

One hundred patients with chronic lymphocytic leukemia and a monoclonal protein in serum or urine were recognized during the period January 1971 to July 1984. IgG monoclonal proteins predominated, with the following distribution: IgG kappa 36% (0.36), IgG lambda 15% (0.15), IgM kappa 27% (0.27), IgM lambda 11% (0.11), IgA lambda 1% (0.01), and free monoclonal light chains in 10% (0.10) (kappa in 8% [0.08] and lambda in 2% [0.02]). The median concentration of M-protein was 1.0 g/dL (10 g/L) or less. The median survival (Kaplan-Meier) for the 100 patients after recognition of an M-protein was six years. The median survival was longer for patients with an IgG monoclonal protein (7.2 years) than for patients with an IgM monoclonal protein (5.2 years), although the difference was not significant. The authors found no important differences in patients with chronic lymphocytic leukemia, whether they had an IgG or an IgM monoclonal protein or a free monoclonal light chain.

Bilateral primary traumatic oculomotor nerve palsy

Two cases with bilateral traumatic oculomotor palsy are presented. The clinical signs, diagnosis criteria, and mechanisms of injury are discussed with a special emphasis on the absence of early reliable prognosis factors. The possibility of recovery depends on the anatomic lesion and not on the ophthalmologic findings in the acute phase.

Ultrasound, computed tomography and magnetic resonance of a neonatal ganglioglioma of the brain

Ganglioglioma is an uncommon nerves-cell tumour (0.4% of all brain tumours). In 800 brain tumours in children, Garrido et al. (Toronto) found 14 gangliogliomas (1.7%). To our knowledge, ganglioglioma has not been reported in children under 2 1/2 years of age. We have incidentally discovered a ganglioglioma in a 3-day-old girl. Appearance on US, CT and MR are described and discussed.

Peroneal motor nerve conduction velocity in diabetic children and adolescents. Relationships to metabolic control, HLA-DR antigens, retinopathy, and EEG

To investigate incipient diabetic neuropathy, peroneal motor nerve conduction velocity (PMNCV) was measured in 61 diabetic children and adolescents whose type 1 diabetes became clinically apparent before the age of 14 years. PMNCV in diabetic patients (48.3 +/- 5.6 m/s) was significantly lower than in controls (56.5 +/- 5.5 m/s), 23 diabetics (36%) having a value more than 2 SD below the mean for normals. There was a highly significant negative correlation between PMNCV and HbA1 levels concomitant with PMNCV measurement or mean annual HbA1 concentrations preceding PMNCV. The relationship between PMNCV and the clinical score of diabetic control since the onset of the disease was also significant. Age, duration of diabetes and HLR-DR antigens were unrelated to PMNCV. EEG abnormalities and retinopathy, whose pathogenesis is different, were not necessarily associated with subclinical neuropathy. Being easy and sensitive, PMNCV determination provides the paediatric diabetologist and the patient himself with an important motivation to improve diabetic control.

Chromosome abnormalities in malignant hematologic disorders

Certain chromosome abnormalities have been detected in routine cytogenetic studies of patients with hematologic disorders. This article is a cytogenetic and clinical review of 28 structural and 15 numeric chromosome abnormalities. As a group, the structural abnormalities involved 40 different chromosome breakpoints and included 13 types of translocations, 8 deletions, 3 isochromosomes, 3 inversions, and 1 duplication. The numeric abnormalities included 4 types of monosomy, 10 trisomies, and a near-haploid category. We determined the relative frequency for each of these anomalies in our practice by reviewing the results of 1,228 consecutive specimens studied between 1979 and 1984 in which a chromosomally abnormal clone was found; 61% of these specimens had one or more of the selected anomalies. The three most common translocations were 9;22 translocations (378 specimens), 8;21 translocations (15 specimens), and unbalanced abnormalities derived from 1;7 translocations (13 specimens). The two most common deletions were those involving the long arm of chromosomes 5 (101 specimens) and 20 (65 specimens). The most common isochromosome was i(17q) (33 specimens). The two most common types of monosomy were loss of a Y chromosome (118 specimens) and monosomy 7 (97 specimens). The three most common trisomies were + 8 (161 specimens), +21 (53 specimens), and +19 (31 specimens). Each of the 43 anomalies was observed in patients with different types of hematologic disorders, but in most cases one kind of neoplasm usually predominated.

Sequential trigeminal sensory neuropathy

In a patient presenting bilateral sensory neuropathy, sequential involvement of the two sides of the face with spontaneous recovery on the initially altered side is a peculiar feature which emphasizes the benign character of this unusual condition. Provided that repeated clinical evaluation discloses no underlying pathological process, sensory trigeminal neuropathy may be considered a self-limited benign condition, comparable to Bell's palsy.

Prognostic value of the topographic grid method in women with T2 N- breast cancer. Statistical results from a series of 203 patients

In 1977, the authors described the grid method, a topographic technique for mapping the microscopic spread of breast cancer. The current report describes the relapse-free survival of a series of 203 patients with T2 N- mammary cancer (T2 N0 N1 ab N-) who were treated by mastectomy and regional lymph node dissection and have been followed since 1974. A good prognosis did not prevent relapse in 15% to 20% of patients within the first 5 years. To determine whether the grid method can identify patients at high risk within this group, disease-free survival and survival were compared in two subsets, a "limited" group (L) and a "diffuse" group (D). The difference between the two groups was statistically significant for both parameters (88%) versus 77% and 93% versus 85% after 5 years) (P less than 0.01 and P less than 0.02). Other prognostic measures were uniformative. Thus, the grid method has a good prognostic score when compared with the factors usually measured--menopausal status, estrogen receptors, histologic type--and could be used to select appropriate adjuvant therapy in breast cancer.

Acute extrapyramidal dysfunction after domperidone administration. Report of a case

The authors relate the observation of a 3-month-old boy who showed acute neurological dysfunction of the extrapyramidal system secondary to the administration of domperidone, a new anti-emetic drug. This drug was first believed not to provoke neurological dysfunction. Yet, this and three other published cases document the possibility of adverse neurological reactions due to domperidone administration.

Comparative immunohistochemical localization of fibronectin and actin in human breast tumor cells in vivo and in vitro

The presence and distribution of fibronectin and actin in breast fibroadenoma cells have been investigated in frozen sections and primocultures of the same samples, by means of indirect immunofluorescence techniques. In the tissue cells, epithelial cells were negative whereas myoepithelial cells were positive with the two antibodies. Moreover, fibronectin was mainly distributed in basal lamina of ducts and ductules whereas actin appeared to label stroma cells. In primocultures obtained from the same samples of fibroadenomas, the labelled patterns of fibronectin and actin were not really distinguishable between cells; the two protein distributions were quite usual. Our data on human breast fibroadenoma cells are in agreement with the concepts of cellular adaptation or selection in culture and emphasize the difficulty in correlating results of "in vitro" and "in vivo" studies.

Non-traumatic clostridial myositis: an unusual feature of brain death

In a case of brain death, a Clostridium sordellii and Escherichia coli septicaemia--of probable gastrointestinal origin--developed and was associated with a diffuse clostridial myositis. Factors responsible for the initiation and development of this unusual clostridial infection are discussed.

HLA-D--related (DRw) antigens in juvenile diabetes mellitus

We studied the distribution of HLA-D--related (DRw) antigens in 40 patients with juvenile diabetes mellitus (JDM) and 79 matched controls. We found that DRw2 was significantly decreased in the JDM group, suggesting a protective effect of the antigen and that the decrease observed in B7 was secondary. HLA-DRw3 and HLA-DRw4 were increased in the diabetic group, and, as with B8/B15, these two antigen predisposed to the disease additively. The susceptibility for JDM was found to be more strongly related to HLA-DRw3 that to B8. On the other hand, B15 rather than DRw4 showed the stronger association with JDM. Moreover, we found that this second diabetogenic gene is associated primarily with B15 and only secondarily with Cw3, which is in linkage disequilibrium with B15. This study further emphasizes the immunogenetic heterogeneity of JDM.

[Early post-traumatic epilepsy in childhood: significance and short term prognosis (author's transl)]

In the last five years, 244 children with head trauma were observed. An early post-traumatic epilepsy was present in 11% of the patients. This complication was more frequent in children less than six years of age or presenting a previous neurological history. Early posttraumatic epilepsy was rarely associated with brain concussion and frequently with cerebral contusion. An intracranial haematoma was not encountered in the absence of the classical signs of expanding space occupying lesion.

Regional cerebral blood flow in children. A rheoencephalographic study of the modifications induced by reading

Cerebral impedance changes (F changes) indicating cerebral blood flow were studied in 17 children aged 6-11 years and in 10 normal adults. At rest, large values were found in children, who never exhibited the 'hyperfrontality' pattern of the adults. Reading induced an F increase in both the dominant and non-dominant hemispheres, in contrast with a larger increase in the dominant hemisphere in adults. A spatial test was designed in adults which triggered a larger increase in the non-dominant hemisphere.