Defective monocyte function in Legionnaires' disease complicating hairy cell leukaemia

We describe a case of Legionnaires' disease in a 64-year-old man, in which hairy cell leukaemia was diagnosed after the onset of the infection. Immunological studies revealed a complete suppression of blood monocyte chemotactic and oxidative burst activities. We suggest that in hairy cell leukaemia both monocytopenia and defective functions of monocytes underlie the increased susceptibility to intracellular infections including Legionnaires' disease.

Vasospastic angina: control of disease activity and efficacy of drug treatment using the prolonged hyperventilation test

Sixteen consecutive patients with vasospastic angina underwent a control provocation test in the coronary care unit or the cardiac catheterization laboratory in order to evaluate the disease activity and the efficacy of long-term calcium antagonist treatment. In patients without angina at rest, the prolonged hyperventilation test was negative in 10/10 patients on calcium antagonist treatment (group A + B) and in 4/5 patients without medication (group C). The test was positive in 1/1 patient with angina at rest without medication (group D). However, the test provoked vasospastic angina in 1/5 patients who were asymptomatic without medication. In both the latter patients the prolonged hyperventilation test became negative after the restart of calcium antagonist treatment. During a mean follow-up period of 18 months (range 16-19) after the control hyperventilation test, no relapse of angina at rest, arrhythmias, syncopes, deaths or myocardial infarctions were registered. Thus, a negative test is compatible with low disease activity and/or efficacy of calcium antagonist treatment. Further, the test may reveal a subclinical tendency to coronary artery spasm.

Plasmapheresis in hyperviscosity syndrome

Three patients with Waldenström's macroglobulinaemia developed circulatory complications due to increased plasma viscosity, i.e. relative viscosity value above 4. Plasmapheresis was performed either in a Haemonetics 30 S cell separator, by plasma filtration through a CPS 10 TM filter or by a double-double pack Fenwal system. All three methods reduced the plasma viscosity and abolished the clinical symptoms. In cases of acute hyperviscosity syndrome, apheresis of small amounts of plasma by the double-double pack system may serve as an alternative to the more advanced techniques.

Demonstration of circulating immune complexes by the indirect leucocyte phagocytosis test in chronic inflammatory bowel disease. Relation to results of a standard complement consumption assay

Circulating immune complexes were studied in untreated Crohn's disease (CD) and ulcerative colitis (UC) by leucocyte phagocytosis. Neutrophils from normal donors took up large immunoglobulin-containing inclusions from 14 of 15 CD sera, 3 of 15 UC sera (p less than 0.002) and from none of 15 reference sera from healthy volunteers (p less than 0.002). In contrast, inclusions could not be demonstrated on direct microscopic investigation. Our study confirms the presence of circulating immune complexes in Crohn's disease. Predominance of IgG-containing complexes in this condition is consistent with a mucosal origin. Discrepant results obtained by direct examination and by incubation of sera from patients with normal test neutrophils suggest a defective immune complex phagocytosis in CD. In consistency with this possibility, control experiments revealed a markedly decreased complex uptake by neutrophils of CD patients in vitro.

Monocyte chemotactic properties in hereditary hemochromatosis

Several observations indicate that the innate metabolic defect in hereditary hemochromatosis (HH) leads to a defective function of the monocyte-macrophage system. The present study was performed to investigate the possibility that a defect in migration of cells of the monocyte-macrophage system can explain the abnormal location of the submucosal macrophages in HH. Monocytes isolated from 14 patients with HH were investigated with regard to chemotactic responsiveness (MCR). Two different methods were used at two different laboratories. Casein and zymosan-activated serum were used as attractants. No difference in MCR was found between the control group and the group of HH patients. The conclusion can therefore be drawn that the abnormal location of the macrophages of the gut wall in HH cannot be explained by an inborn abnormality of the function of receptors responsible for the chemotactic activity of the monocyte-macrophage system. It is, however, still possible that local factors responsible for the macrophage migration (gut hormones?) may have defective activity in HH patients.

A survey for circulating immune complexes in patients with acute myocardial infarction. Use of a C1q-binding assay with soluble protein A as indicator

A new assay for the detection of circulating C1q-binding immune complexes (IC) is described. The assay makes use of solid-phase C1q and iodinated soluble protein A, extracted from the cell wall of Staphylococcus aureus. In a model system the assay could detect heat-aggregated IgG down to a concentration of about 50 ng/ml. This method and three other assays, previously described, were used to survey the appearance of IC activity in sera from hospitalized patients with acute myocardial infarction. Depending on the assay system used, from 56% to 66% of the patients investigated were found to develop circulating IC. The earliest appearance of circulating IC was noted 5 days after infarction. The highest incidence of positive reactions and the strongest reactions occurred 2 to 3 weeks after hospitalization; thereafter the IC positiveness tapered off, and all patients were negative 6 weeks after infarction.

Is the incidence of perimyocarditis increased following Campylobacter jejuni infection?

Preliminary case reports have suggested an association between Campylobacter jejuni infection and occurrence of perimyocarditis. In the present study we analysed the incidence of perimyocarditis requiring hospitalization in a Danish cohort of 6,204 patients with Campylobacter-positive stool cultures and compared it to the incidence in a matched control cohort comprising 62,040 subjects. We found no cases of pericarditis in the Campylobacter population and an incidence rate of 3.2 [95% confidence interval (CI): 0.8-12.9] per 100,000 person-years in the control population. The incidence rate of myocarditis was 16.1 (95% CI: 2.3-114.4) per 100,000 person-years in the Campylobacter population compared to 1.6 (95% CI: 0.2-11.4) per 100,000 person-years in the control cohort. We found no statistically significant difference in perimyocarditis between the two groups.

EULAR recommendations for the management of early arthritis: report of a task force of the European Standing Committee for International Clinical Studies Including Therapeutics (ESCISIT)

OBJECTIVE

To formulate EULAR recommendations for the management of early arthritis.

METHODS

In accordance with EULAR's "standardised operating procedures", the task force pursued an evidence based approach and an approach based on expert opinion. A steering group comprised of 14 rheumatologists representing 10 European countries. The group defined the focus of the process, the target population, and formulated an operational definition of "management". Each participant was invited to propose issues of interest regarding the management of early arthritis or early rheumatoid arthritis. Fifteen issues for further research were selected by use of a modified Delphi technique. A systematic literature search was carried out. Evidence was categorised according to usual guidelines. A set of draft recommendations was proposed on the basis of the research questions and the results of the literature search.. The strength of the recommendations was based on the category of evidence and expert opinion.

RESULTS

15 research questions, covering the entire spectrum of "management of early arthritis", were formulated for further research; and 284 studies were identified and evaluated. Twelve recommendations for the management of early arthritis were selected and presented with short sentences. The selected statements included recognition of arthritis, referral, diagnosis, prognosis, classification, and treatment of early arthritis (information, education, non-pharmacological interventions, pharmacological treatments, and monitoring of the disease process). On the basis of expert opinion, 11 items were identified as being important for future research.

CONCLUSIONS

12 key recommendations for the management of early arthritis or early rheumatoid arthritis were developed, based on evidence in the literature and expert consensus.

High incidence of intravascular focus in nontyphoid Salmonella bacteremia in the age group above 50 years: a population-based study

Questions regarding the relative frequency of vascular complications in nontyphoid Salmonella bacteremia are pending, and the true population-based age-related incidence is not known. We reviewed all cases of nontyphoid Salmonella bacteremia during a 10-year period from 1994 through 2003 in a well-defined population of 492,843 residents in North Jutland County, Denmark. 77 of a total of 111 cases occurred in patients >50 years old. In this age group, five cases of mycotic aneurysm and two cases of endocarditis were documented, corresponding to a 9% occurrence. The annual incidence rate of endovascular nontyphoid Salmonella infection in this age group was 4.4 per 1,000,000 person years. The mortality was 43% in cases with endovascular infection, and surgical procedures were important for survival. We conclude that in patients older than 50 years, detection of nontyphoid Salmonella bloodstream infection should be followed by examinations for mycotic aneurysms and endocarditis.

'Simply forgot' is the most frequently stated reason for missed doses of HAART irrespective of degree of adherence

OBJECTIVES

Previous studies have reported that forgetfulness is the most frequently mentioned reason for missed doses among patients on highly active antiretroviral therapy (HAART). However, no previous study has compared the reasons given by highly nonadherent patients with the reasons given by patients with better adherence. The objective of this study was to examine further patients' self-reported reasons for missing doses of HAART and to compare the reasons given by patients with lower adherence with those given by patients with higher adherence.

METHODS

All patients visiting the clinics participating in the Danish HIV cohort study during a 1-year period (July 2002 to June 2003) were eligible if they had started HAART at least 6 months previously. Consenting patients completed an anonymous self-administered questionnaire based upon the adult AIDS Clinical Trial Group adherence questionnaires. Lower adherence was defined as reporting a missed dose within the preceding 4 days.

RESULTS

We received usable questionnaires from 840 (75%) of the 1126 eligible patients. Patients with lower adherence reported the same reasons for missed doses as patients with higher adherence (Spearman's rho=0.952, P<0.0001). In both groups of patients the three most frequently reported reasons for missed doses were 'simply forgot', 'were away from home', and 'had a change in daily routines'.

CONCLUSIONS

Patients with poorer adherence to HAART state the same reasons for missing doses as patients with better adherence, and 'simply forgot' is the most frequently stated reason.

Incidence and prognosis of non-typhoid Salmonella bacteraemia in Denmark: a 10-year county-based follow-up study

The aim of this study was to examine the incidence and prognosis of non-typhoid Salmonella bacteraemia in a well-defined population in which complete follow-up investigations had been performed. All patients with non-typhoid Salmonella bacteraemia from 1994 through 2003 in North Jutland County, Denmark, were eligible for the study. Annual incidence rates were calculated for 10-year age groups. The North Jutland County Bacteraemia Database (inclusion of subjects), medical hospital records, the Prescription Registry (redemption of prescription drugs), and the Central Population Registry (deaths) were used as data sources. The outcomes were mortality within 30 and 180 days of the first non-typhoid-Salmonella-positive blood sample. Cox proportional-hazards regression analysis was performed, first with age and comorbidity as evidenced by Charlson index scores, and second with selected clinical and laboratory prognostic variables potentially related to non-typhoid Salmonella bacteraemia per se. A total of 111 non-typhoid Salmonella bacteraemia patients were included in the study. The incidence rate (mean 2.3/100,000 person-years) increased steadily from 1.9/100,000 person-years in the 40-49-year age group to 14.6/100,000 person-years in those >90 years. Twelve (11%) and 24 (22%) patients died within 30 and 180 days, respectively. Cox regression analyses showed that increasing age and, to a higher degree, increasing levels of comorbidity were independently associated with an unfavourable outcome, whereas none of the clinical or laboratory variables studied were strong independent prognostic factors. In conclusion, the presence of comorbid diseases and old age were independently associated with mortality, whereas clinical and laboratory variables were less important.

Severity of infection and seasonal variation of non-typhoid Salmonella occurrence in humans

Non-typhoid Salmonella infections may present as severe gastroenteritis necessitating hospitalization and some patients become septic with bacteraemia. We hypothesized that the seasonal variation of non-typhoid Salmonella occurrence in humans diminishes with increased severity of infection. We examined the seasonal variation of non-typhoid Salmonella infections in three patient groups with differing severity of infection: outpatients treated for gastroenteritis (n=1490); in-patients treated for gastroenteritis (n=492); and in-patients treated for bacteraemia (n=113). The study was population-based and included all non-typhoid Salmonella patients in a Danish county from 1994 to 2003. A periodic regression model was used to compute the peak-to-trough ratio for the three patient groups. The peak-to-trough ratios were 4.3 [95% confidence interval (CI) 3.6-5.0] for outpatients with gastroenteritis, 3.2 (95% CI 2.4-4.2) for in-patients with gastroenteritis, and 1.6 (95% CI 1.0-2.8) for in-patients with bacteraemia. We conclude that the role of seasonal variation diminishes with increased severity of non-typhoid Salmonella infection.

Pronounced lipoatrophy in HIV-infected men receiving HAART for more than 6 years compared with the background population

OBJECTIVES

To establish the prevalence and quantify the severity of body fat redistribution and dyslipidaemia in HIV-infected men after long-term highly active antiretroviral therapy (HAART) compared with the background population.

METHODS

In a cross-sectional study, we included 87 HIV-infected men who had received HAART for at least 6 years and 34 HIV-negative men. Regional body composition was assessed using dual-energy X-ray absorptiometry. Fasting metabolic parameters were obtained. Associations between regional body fat distribution and metabolic parameters were evaluated.

RESULTS

HIV-infected patients and controls did not differ with regard to height and lean body mass. Compared with controls, HIV-infected men had reduced total fat mass (median 12.3 versus 19.2 kg, P<0.001), limb fat mass (4.3 versus 7.9 kg, P<0.001), and trunk fat mass (6.7 versus 10.8 kg, P<0.001) and higher trunk/limb fat ratio (1.7 versus 1.2, P<0.001). Also, patients without clinical lipodystrophy had reduced amounts of limb and trunk fat. In HIV-infected men, triglyceride levels were higher (2.0 versus 1.2 mmol/L, P<0.001), high-density lipoprotein (HDL)-cholesterol levels were lower (1.2 versus 1.3 mmol/L, P<0.05) and insulin levels were higher (40.8 versus 29.9 pmol/L, P<0.01) than in controls. All adverse metabolic parameters correlated with increased trunk/limb fat ratio, and insulin levels correlated positively with trunk fat mass (P<0.01).

CONCLUSION

Peripheral as well as central fat loss is a general characteristic of HIV-infected men after long-term HAART. Although lipoatrophy was the dominant morphological presentation, the adverse metabolic parameters were mainly associated with the increased ratio of trunk/limb fat.

A Randomized Trial to Evaluate Lopinavir/Ritonavir versus Saquinavir/Ritonavir in HIV-1-Infected Patients: The Maxcmin2 Trial

Objective

To assess the rate of protocol-defined treatment failure and safety of lopinavir/ritonavir (LPV/r) and saquinavir/ritonavir (SAQ/r).

Design

Open-label, prospective, randomized (1:1), international multi-centre trial.

Methods

Adult HIV-1-infected patients were assigned LPV/r 400/100 mg twice daily or SAQ/r 1000/100 mg twice daily with two or more nucleoside reverse transcriptase inhibitors (NRTIs)/non-NRTIs. All patients, whether on or off the assigned treatment, were followed for 48 weeks.

Results

Of 339 randomized patients, 324 initiated assigned treatment (intention-to-treat/exposed [ITT/e] population). At 48 weeks, treatment failure occurred in 29/163 (18%) and 53/161 (33%) of patients in the LPV/r and SAQ/r arms, respectively (ITT/e, P=0.002, log rank test). In an analysis that also considered those patients who discontinued treatment as having failed treatment (ITT/e/discontinuation=failure), 40/161 (25%) LPV/r-treated individuals versus 63/161 (39%) SAQ/R-treated individuals failed treatment ( P=0.005, log rank test). Discontinuation of the assigned treatment occurred in 23/163 (14%) patients in the LPV/r-treated group, compared with 48/161 (30%) in the SAQ/r-treated group (ITT/e; P=0.001). The primary reasons for premature discontinuation were non-fatal adverse events (LPV/r: 12/163; SAQ/r: 21/161) and patients’ choice (LPV/r: 7/163; SAQ/r: 8/161). In the on-treatment analysis of time to treatment failure, no difference was observed between the two arms ( P=0.27, log rank test).

Conclusion

LPV/r had better antiretroviral effects compared with SAQ/r at the doses and in the formulations studied. This may have been a result of patients’ preferences and ability to adhere to assigned therapy, rather than a result of differences in the intrinsic potency of the study protease inhibitors.

Community-acquired adenovirus pneumonia in a patient with chronic lymphatic leukaemia

Described here is a severe case of community-acquired adenovirus pneumonia that occurred in a previously healthy 54-year-old male who was later determined to have stage A chronic lymphatic leukemia. The clinical presentation was consistent with that of atypical pneumonia. Testing with PCR revealed adenovirus in a bronchoalveolar lavage sample, while all other tests to determine a bacterial or virological etiology were negative. Further examination of the patient revealed the previously undiagnosed chronic lymphatic leukemia. Following treatment with human immunoglobulin and oxygen therapy with continuous positive airway pressure support the patient recovered from the pneumonia completely.

Magnetic resonance imaging for accelerated assessment of drug effect and prediction of subsequent radiographic progression in rheumatoid arthritis: a study of patients receiving combined anakinra and methotrexate treatment

OBJECTIVES

By MRI to assess the efficacy of addition of anakinra for controlling synovitis and stopping erosive progression in patients with clinically active RA despite receiving methotrexate, and to determine the predictive value of MRI for subsequent radiographic erosive progression.

METHODS

100 mg anakinra subcutaneously/day was added to the treatment of 17 patients with clinically active RA despite methotrexate. MRI of the non-dominant wrist and 2nd-5th MCP joints (OMERACT evaluation) was performed at weeks 0, 12, and 36, and radiography of both hands and wrists (modified Sharp evaluation) at weeks 0 and 36.

RESULTS

MRI synovitis scores were not significantly changed. Radiography of both hands and wrists after 36 weeks showed erosive progression in 11 patients, and MRI after 12 weeks in 10 patients. Nine of 10 patients with MRI progression at 12 weeks had radiographic progression at 36 weeks. Baseline MRI synovitis and erosion scores, but no clinical/biochemical parameters, correlated significantly with subsequent erosive progression.

CONCLUSION

Addition of anakinra did not significantly reduce MRI signs of synovitis, and most patients had progressive joint destruction. Baseline MRI findings predicted subsequent radiographic erosive progression. Unilateral wrist and MCP joint MRI after 12 weeks had a similar sensitivity for detection of erosive progression as bilateral hand and wrist radiography after 36 weeks.