Efficacy of Valganciclovir in the Treatment of Cytomegalovirus Disease in Kidney and Pancreas Transplant Recipients

Cytomegalovirus (CMV) disease is relatively common following solid organ transplant, particularly if a serologically negative recipient receives an organ from a serologically positive donor (D+/R-). Although valganciclovir is approved for the treatment of CMV retinitis in AIDS patients and is used for the prophylaxis against CMV infection in solid organ transplant patients, the current standard treatment for CMV disease in solid organ transplant recipients remains intravenous ganciclovir. We retrospectively reviewed our experience using valganciclovir as treatment for CMV disease in CMV D+/R- kidney and/or pancreas transplant recipients from March 2002 to June 2005. A total of 37 cases with primary CMV disease were diagnosed and treated with either intravenous ganciclovir as induction followed with valganciclovir or valganciclovir from the beginning. We compared clinical outcomes and viremia between the two groups. Our data suggest that valganciclovir is an effective treatment modality for primary CMV disease in kidney and/or pancreas transplant recipients. It led to the resolution of disease and undetectable viremia. Valganciclovir allowed for early initiation of treatment and for treatment to be given as an outpatient. These advantages of valganciclovir have both health and economic impact for patients with CMV disease.

Suture Foreign Body Granuloma Masquerading as Renal Neoplasm

Foreign body granulomas and pseudotumors due to retained surgical linen are well known in surgical practice. These lesions usually correspond to the actual size of residual foreign body and have characteristic presentation according to the anatomy involved. Renal suture granuloma is a rare postoperative complication of renal surgery due to persistence of sutures used to close the pelvicalyceal system/nephrotomy incisions and usually present as incidentally detected small mass lesions. This case of a suture foreign body granuloma presenting with hematuria, large peripheral mass lesion and characteristic computed tomography picture of renal cell carcinoma confounded the diagnosis and underwent laparoscopic radical nephrectomy. In retrospect, such lesions warrant the use of selective needle biopsy and intraoperative frozen section confirmation to clinch diagnosis. Mass lesions occurring in a previously operated kidney should have granuloma as a differential diagnosis.

An experimental design for induction of non-specific aortoarteritis

BACKGROUND

An attempt was made to induce aortoarteritis in mice by using various antigens.

METHODS AND RESULTS

The Swiss mice were immunized with eight different antigens and were grouped A to G. Group H served as control. The mice were then bled at 1st, 2nd, 4th, 6th and 8th month interval post-immunization for estimating antibody titer. Then the mice were sacrificed and the heart, aorta and kidney were taken out and processed for hematoxylin-eosin staining. There was gradual increase in the antibody titer from 1st month till 4th month within all the experimental groups (A-G), when compared with control group H. The titer started falling sharply from 6th month post-immunization. However, the control group H did not show much variation. When each individual group was compared separately with control group H, the significant statistical value was obtained. Histopathological examination revealed mild inflammation (+) in kidney by 2nd month, moderate inflammation (++) by 6th month, extensive inflammation (+++) by 8th month and alteration in the normal parenchyma of kidney by 8th month.

CONCLUSIONS

The histopathological changes brought out through antigens were more pronounced by 8th month following injection of tunica media, tunica adventitia, tunica intima and aorta collagen as compared to that of standard collagen and mouse aorta injections.

Post-kala-azar dermal leishmaniasis: A histopathological study

BACKGROUND

Post-kala-azar dermal leishmaniasis follows an attack of visceral leishmaniasis and is caused by the same organism, i.e. Leishmania donovani.

METHODS

In the present study, biopsy specimens from hypopigmented macules, nodules or plaques of 25 patients clinically diagnosed as PKDL were evaluated for epidermal and dermal changes and for the presence or absence of Leishmania donovani bodies (LDBs).

RESULTS

The hypopigmented macules showed a patchy perivascular and periappendageal infiltrate with no demonstrable LDBs in any of the biopsies. In the nodular and plaque lesions, the infiltrate was diffuse, beneath an atrophic epidermis (74%) and follicular plugging (95.6%) was seen in most biopsies. The infiltrate consisted of lymphocytes, histiocytes and plasma cells in decreasing order of presence. LDBs could be demonstrated in only 10 (43.5%) biopsy specimens from nodular and plaque lesions and were never numerous.

CONCLUSIONS

Histopathological features of PKDL are elucidated and discussed.

Mucosal and peri-orificial involvement in post-kala-azar dermal leishmaniasis

BACKGROUND AND AIMS

Lesions of post-kala-azar dermal leishmaniasis (PKDL) usually affect the skin. Uncommonly, the involvement of oral and genital mucosae has been reported.

METHODS

Twenty five patients clinically diagnosed as post-kala-azar dermal leishmaniasis were studied for periorificial and mucosal lesions. Clinical examination, skin smears and biopsy were done for the patients with periorificial or mucosal lesions.

RESULTS

Out of 25 patients of PKDL, seven patients had lesions on the oral and/or genital mucosa. Three cases had oral lesions; two had only genital lesions and three patients had both sites involved. All the patients were having skin lesions elsewhere too either as nodules and/or plaque or macules.

CONCLUSION

While examining a case of PKDL, mucosal involvement must also be examined carefully.

Therapeutic trial of sodium antimony gluconate alone and in combination with ketoconazole in post-kala-azar dermal leishmaniasis

BACKGROUND

Drugs used in PKDL include parenteral sodium antimony gluconate (SAG), amphotericin-B, pentamidine, and ketoconazole (KTZ). SAG is the most effective one. Given alone, SAG has to be given for a long duration, leading to poor patient compliance and treatment failure. This study was carried out to compare the effectiveness of SAG alone and a combination of SAG and KTZ for sixty days.

METHODS

Ten patients of PKDL were included in the study. Five patients (Group A) were given SAG intravenously, in the dose of 20 mg/kg per day and five (Group B) were given SAG (intravenously 20 mg/kg per day) and KTZ (200 mg twice daily orally). Both treatment regimens were given for sixty days.

RESULTS

In Group A, the nodules and/or plaques showed approximate 80-85% clinical improvement, and macules showed 25-30% improvement. In group B (SAG + KTZ), there was 90-95% clinical improvement in the nodules and/or plaques and 25-30% in macules.

CONCLUSION

This study suggests the therapeutic superiority of the combination treatment regimen in a shorter duration but is not conclusive as the number of patients was low. Further trials are recommended.

Cardiac myxoma with glandular elements: a histologic, histochemical, and immunohistochemical evaluation

Epithelial differentiation in cardiac myxoma is a rare phenomenon. Out of 104 surgically excised specimens, we studied 3 cases of cardiac myxoma with glandular differentiation. All the cases had well formed glands in addition to the myxoma cells lying in a myxoid background. Detailed histochemical and immunohistochemical studies suggest that the epithelial islands in cardiac myxoma show an enteric phenotype.

Primary care work-up of acute and chronic symptoms

Low back pain may present as acute pain or as an acute exacerbation of a chronic pain problem. Acute low back pain is self-limited, with 90% of affected individuals recovering within 3 weeks to 3 months. Pain duration of more than 4 weeks warrants a more complete work-up, including ruling out malignancy. Pain duration of more than 6 months defines chronic pain, which is frequently associated with affective and behavioral components. When taking the history, determine pain intensity, location, pattern of radiation, onset, and duration. A gentle physical exam may help locate the source of pain through palpation and maneuvers, such as the straight leg raise test. Imaging is recommended for patients with a clinical finding that raises suspicion of spinal malignancy.

Guide to conservative, medical, and procedural therapies

For patients without a specific diagnosis, treatment of low back pain begins with strategies to avoid re-injury and exacerbation. Most patients benefit from some form of medical therapy, guided by the three-step World Health Organization analgesic ladder. Opioid therapy is appropriate when needed for low back pain, especially in the acute period. Adjuvant medication (eg, an anticonvulsant or antidepressant) may help reduce or eliminate the need for opioid therapy. Side effects are common with opioid medications, although many resolve with time. Patient education in exercise, back protection, nutrition, and sexual concerns is an important component of treatment. Some patients may benefit from referral to a pain center for multidisciplinary management. Those with a structural or mechanical cause of pain may do well with surgery.

Isolated cardiac aspergillosis

A 40-year-old man, a known case of Wolff-Parkinson-White syndrome, was admitted to the hospital in an unconscious state. In spite of medical treatment, the patient died within two hours of admission. At autopsy, the deceased was found to have aspergillosis involving the interatrial septum, aortic valve and root of the aorta. The rest of the organs were unremarkable. The patient did not show any obvious signs of being immunocompromised. We report this case of isolated cardiac aspergillosis in an apparently healthy individual.

Fatal atypical mycobacterial infection in a cardiac transplant recipient

A 37-year-old female underwent heart transplantation for giant cell myocarditis. The patient died within three-and-a-half months of cardiac transplantation. Postmortem specimens from the heart and lung showed multiple necrotizing granulomas with numerous acid-fast bacilli. Polymerase chain reaction done on both the postmortem samples confirmed the presence of atypical mycobacterial infection. This fatal case of atypical mycobacteriosis in a cardiac transplant patient is reported for its rarity.

Homograft mitral valve replacement: five years' results

OBJECTIVE

Results of mitral valve replacement with a mitral homograft were evaluated at 5 years to assess the suitability of the procedure.

METHODS

Thirty-seven patients (25 male subjects) aged 10 to 49 years (mean, 32 +/- 10 years) with rheumatic mitral valve disease underwent total (n = 35) or partial (n = 2) mitral valve replacement with a fresh antibiotic-preserved (n = 23) or cryopreserved (n = 14) mitral homograft. The predominant lesion was mitral stenosis (n = 30).

RESULTS

There were 5 early deaths. Operative survivors were followed up for 1 to 60 months (mean, 26.6 +/- 12 months). Among these, 21 patients had severe mitral regurgitation during the follow-up period; 3 died and 8 underwent reoperation. The homograft failure rate was not affected by preoperative physiologic lesion (stenosis vs regurgitation, P =.4), type of homograft (antibiotic-preserved vs cryopreserved homograft, P =.9), papillary muscle pretreatment (yes vs no, P =.9), or addition of posterior collar annuloplasty (yes vs no, P =.2). Among the remaining patients, 5 had moderate mitral regurgitation, 4 had either trivial or mild mitral regurgitation, and 2 were lost to follow-up. Study of the explanted mitral homografts (n = 8) revealed that disruption of one of the donor papillary muscles was responsible for early failures (n = 2), whereas cuspal and chordal degeneration was responsible for late failures (n = 6). Microscopically, the explanted valve lacked any viable cellular elements, and there was no evidence of immunologic injury to the homografts.

CONCLUSION

The mitral homograft did not fulfill our expectations as a suitable substitute for the diseased mitral valve.

Non-myxomatous cardiac tumours: twenty-year experience

Eighty-eight patients underwent surgery for various cardiac tumours from January 1978 to June 1998 at our Institute. Seventy-seven tumours were myxomas, 10 were non-myxomatous and one was secondary cardiac tumour. Case records of the patients with non-myxomatous primary cardiac tumours and one secondary tumour were reviewed. Six of these primary tumours were benign and four, malignant. Age of the patients ranged from 26 days to 47 years. Among patients (3 children, 8 adults) with non-myxomatous primary cardiac tumours, dyspnoea on exertion was the commonest symptom and was the cause of presentation in seven out of 11 patients. Of the eight adults, six were in New York Heart Association functional class II/III and two in class IV. Echocardiographic diagnosis was possible in all the patients. Complete excision of the tumour was possible in all benign and two of the four malignant tumours. Incomplete resection was done in the secondary tumour. Of the six benign tumours, three were rhabdomyomas and one each of fibroma, haemangioma and lipoma. The malignant tumours were one each of fibrosarcoma, angiosarcoma, unclassified sarcoma and malignant mesothelioma. The secondary tumour was a malignant thymoma. Follow-up ranged from 1 to 10 years (mean 7.2 years). Of the patients with benign tumours, four out of six are alive; one patient died on the first post-operative day and one lost to follow-up. Two of the four patients with malignant cardiac tumours died, one was lost to follow-up and one is alive two years after surgery. The patient with secondary malignant thymoma to the superior vena cava was lost to follow-up three months after an uneventful recovery from surgery.

Bcl-2 expression is correlated with low apoptotic index and associated with histopathological grading in esophageal squamous cell carcinomas

The aim of this study was to examine the relationship between apoptosis, protein expression of apoptosis mediator and inhibitor genes p53 and bcl-2 and various histopathological grades of squamous cell carcinoma of the esophagus. Apoptotic index was evaluated in thirty human esophageal squamous cell carcinomas and adjoining normal tissue by terminal deoxynucleotidyl transferase-mediated dUTP nick end labelling (TUNEL). Protein expression of bcl-2 and p53 was measured by immunohistochemical staining of cryocut sections and Western blotting. Apoptototic cells were seen mainly around areas of keratinization and the apoptotic index was highest in well-differentiated squamous cell carcinomas. High Bcl-2 expression correlated inversely with the apoptotic index. p53 protein expression did not correlate with the grade of the tumor or the apoptotic index. We propose that deregulation of apoptosis contributes to the pathogenesis of esophageal squamous cell carcinoma.

A method for extraction of high-quality and high-quantity genomic DNA generally applicable to pathogenic bacteria

In this study, we report a modified procedure for extraction of high-quality genomic DNA that is rapid, simple, biologically nonhazardous, and generally applicable to pathogenic bacteria. Bacterial cells were pretreated with 70% ethanol prior to enzymatic digestion with lysozyme. Exposure of bacterial cells to 70% ethanol sterilized the cultures, making the process biologically safe and increased the susceptibility of the cells to lysozyme-induced lysis. Consistently high yields of genomic DNA (mean average yield, 0.5-2.5 mg/ml) were obtained from 465 isolates representing over 30 clinically important bacterial species. Genomic DNA obtained was determined to be suitable for further analysis, including bacterial fingerprinting techniques like restriction endonuclease analysis, Southern hybridization, and repetitive PCR. Availability of a generally applicable procedure for extraction of high-quality and high-quantity genomic DNA would be immensely beneficial for laboratories engaged in molecular surveillance of nosocomial and community-based outbreaks.

Usefulness of antimyosin antibody imaging for the detection of active rheumatic myocarditis

Myocarditis constitutes an important component of rheumatic carditis. Antimyosin scintigraphy, which allows noninvasive assessment of myocyte damage, can be used for documentation of cardiac involvement in patients with rheumatic fever where clinical diagnosis is not unequivocal.

Pulmonary autograft: should it be used in young patients with rheumatic disease?

BACKGROUND

Although pulmonary autograft is being increasingly used to replace the diseased aortic valve with excellent long-term results, its use in the population with rheumatic disease still needs careful evaluation.

PATIENTS AND METHODS

From October 1993 through March 1998, 102 patients underwent aortic valve replacement with a pulmonary autograft (Ross procedure). The mean age was 27.9 +/- 4.2 years (range, 0.8-56 years). The cause was rheumatic disease in 75 patients (73%), bicuspid aortic valve in 26 patients (26%), and myxomatous aortoarteritis in 1 patient (1%). The root replacement technique was used in all. In addition, 31 patients had 33 associated procedures: mitral valve repair (n = 15 patients), open mitral commissurotomy (n = 15 patients), tricuspid repair (n = 2 patients), and homograft mitral valve replacement (n = 1 patient).

RESULTS

Operative mortality was 6.9% (7 patients). Late mortality was 7.8% (8 patients). Follow-up ranged from 1 to 60 months (mean, 25.3 +/- 15.4 months) and was 98% complete. Two patients required reoperation for failed mitral valve repair, and 2 other patients underwent reoperation for failure of both the autograft and mitral valve repair. Echocardiographic assessment showed moderate to severe aortic regurgitation in 13 patients, along with thickening of the autograft. All of these patients had rheumatic disease and were young (<30 years). Ten of these patients had undergone associated mitral valve procedure. Morphologic and histopathologic examination of explanted autografts showed features compatible with rheumatic valvulitis.

CONCLUSION

Pulmonary autograft is susceptible to rheumatic involvement. Young age (<30 years) and associated mitral valve disease are significant risk factors for autograft failure in patients with rheumatic disease. Use of pulmonary autograft in this subgroup of patients requires a cautious approach.

Cholelithoptysis and pleural empyema

We report a case of delayed cholelithoptysis and pleural empyema caused by gallstone spillage at the time of laparoscopic cholecystecomy. An occult subphrenic abscess developed, and the patient became symptomatic only after trans-diaphragmatic penetration occurred. This resulted in expectoration of bile, gallstones, and pus. Spontaneous decompression of the empyema occurred because of a peritoneo-pleuro-bronchial fistula. This is the first case of such managed nonoperatively and provides support for the importance of intraoperative retrieval of spilled gallstones at the time of laparoscopic cholecystectomy.

Appraisal of histogenesis of cardiac myxoma: our experience of 78 cases and review of literature

Cardiac tumours are uncommon. Of these, myxomas have generated significant interest, not only because it is the commonest cardiac neoplasm but also because of controversial theories regarding its histogenesis. We encountered 78 cases of cardiac myxoma in our centre between 1976 and 1997. These included 73 sporadic cases and five cases from a single family of mother, daughter and son. The familial cases had recurrent, biatrial cardiac myxomas. Histopathologic analysis, immunohistochemical study, electron microscopic evaluation and DNA ploidy analysis done in some of these cases revealed evidence in support of the neoplastic nature of this entity. This communication sums up our observations and literature related to the histogenesis of cardiac myxoma.

Congenital gingival granular cell tumor--a case report

Presented here is a case report of a congenital granular cell tumor commonly known as congenital epulis. It has been found to be ten time more common in females as compared to males. The most common presenting problem is that of difficulties in feeding and respiration. Surgical excision is indicated in case the above problems are present. In the absence of any respiratory or feeding difficulties it is advisable to wait for spontaneous regression.