Insufficiency fractures of the sternum

Insufficiency fractures occur within weakened bones that are unable to withstand the stress of every day normal activities. The spine, pelvis, and lower long-bone extremities are common sites of insufficiency fractures. Spontaneous sternal insufficiency fracture (SIF) has rarely been reported in elderly patients. To recognise a sternal insufficiency fracture is important in selecting the adequate diagnostic procedures.

Vascular endothelial growth factor levels in the serum and synovial fluid of patients with rheumatoid arthritis

OBJECTIVE

To determine the vascular endothelial growth factor (VEGF) concentrations in serum and synovial fluid (SF) from patients with rheumatoid arthritis (RA) and to search for relationships between VEGF levels and clinical and laboratory variables.

METHODS

We measured VEGF levels using an enzyme-linked immunosorbent assay. Serum samples were obtained from 99 RA patients, 49 osteoarthritis (OA) patients, and 80 normal controls. Paired samples of serum and SF were collected from 32 patients with RA and 15 with OA.

RESULTS

The mean serum VEGF concentration was 590.1 pg/ml for RA patients, 286.7 pg/ml for OA patients, and 265.8 pg/ml in controls. The serum VEGF concentration was significantly higher in the RA patients than in the OA patients or the controls (both p < 0.001). Furthermore, the VEGF levels in SF from RA patients were significantly higher than in SF from OA patients (p = 0.017). However, there was no correlation between VEGF levels in serum and SF from the same RA patients. The serum VEGF concentration was correlated with the ESR, serum CRP concentration, serum rheumatoid factor, number of tender and swollen joints, Modified Health Assessment Questionnaire, and patient and physician global assessments of disease activity in RA patients.

CONCLUSION

These results suggest that VEGF level is related to RA disease activity, suggesting that VEGF may play some role in the pathogenesis of RA.

Decreased production of interleukin-12 and interferon-gamma is associated with renal involvement in systemic lupus erythematosus

OBJECTIVE

To analyze the type 1/type 2 cytokine balance in patients with systemic lupus erythematosus (SLE) according to the presence of renal disorder and activity status.

METHODS

We measured the serum levels of type 1 (IFN-gamma, IL-12) and type 2 cytokines (IL-4, IL-10) as well as spontaneous and stimulated cytokine production from peripheral blood mononuclear cells (PBMC) in 40 patients with SLE.

RESULTS

Patients with lupus nephritis (LN) showed significantly lower levels of serum IL-12 and IFN-gamma than those without LN. Production of IL-12 and IFN-gamma by stimulated PBMC were also decreased in patients with LN. The circulating IL-12 correlated positively with IFN-gamma, but inversely with IL-10. The SLEDAI scores correlated well with the ratio of IL-4/IFN-gamma levels.

CONCLUSION

The reduced production of IL-12 and IFN-gamma and the resultant shift towards the type 2 cytokine phenotype may be associated with LN.

A case of cholestatic autoimmune hepatitis and acute liver failure: an unusual hepatic manifestation of mixed connective tissue disease and Sjögren's syndrome

Although hepatomegaly is reported to occur occasionally in patients with mixed connective tissue disease (MCTD) or Sjögren's syndrome (SS), autoimmune liver diseases such as primary biliary cirrhosis, sclerosing cholangitis, and autoimmune hepatitis in association with MCTD or SS have rarely been described. We report a case of severe cholestatic autoimmune hepatitis presenting with acute liver failure in a 40-yr-old female patient suffering from MCTD and SS. The diagnosis of MCTD and SS was made at the age of 38. The patient presented severe jaundice and elevation of conjugated bilirubin. The patient denied alcohol and drug use and had no evidence of viral hepatitis. On the 8th day of her hospitalization, the patient developed grade III hepatic encephalopathy. She was diagnosed as autoimmune hepatitis presenting with acute liver failure based on clinical features, positive FANA and anti-smooth muscle antibodies, negative anti-mitochondrial antibodies, high titers of serum globulin, liver biopsy findings, and a good response to corticosteroid therapy, The patient was managed with prednisolone and the clinical symptoms, liver function test results, and liver biopsy findings showed much improvement after steroid therapy.

Sphingosine 1-phosphate protects human umbilical vein endothelial cells from serum-deprived apoptosis by nitric oxide production

Sphingosine 1-phosphate (S1P) can prevent endothelial cell apoptosis. We investigated the molecular mechanisms and signaling pathways by which S1P protects endothelial cells from serum deprivation-induced apoptosis. We show here that human umbilical vein endothelial cells (HUVECs) undergo apoptosis associated with increased DEVDase activity, caspase-3 activation, cytochrome c release, and DNA fragmentation after 24 h of serum deprivation. These apoptotic markers were suppressed by the addition of S1P, the NO donor S-nitroso-N-acetylpenicillamine (100 micrometer), or caspase-3 inhibitor z-VAD-fmk. The protective effects of S1P were reversed by the nitric-oxide synthase (NOS) inhibitor N-monomethyl-l-arginine, but not by the soluble guanylyl cyclase inhibitor 1H-(1,2,4)oxadiazolo[4,3-a]-quanoxaline-1-one, suggesting that NO, but not cGMP, is responsible for S1P protection from apoptosis. Furthermore, S1P increased NO production by enhancing Ca(2+)-sensitive NOS activity without changes in the eNOS protein level. S1P-mediated cell survival and NO production were suppressed significantly by pretreatment with antisense oligonucleotide of EDG-1 and partially by EDG-3 antisense. S1P-mediated NO production was suppressed by the addition of pertussis toxin, an inhibitor of G(i) proteins, the specific inhibitor of phospholipase C (PLC), and the Ca(2+) chelator BAPTA-AM. These findings indicate that S1P protects HUVECs from apoptosis through the activation of eNOS activity mainly through an EDG-1 and -3/G(i)/PLC/Ca(2+) signaling pathway.

A soluble auxin-binding protein, ABP57. Purification with anti-bovine serum albumin antibody and characterization of its mechanistic role in the auxin effect on plant plasma membrane H+-ATPase

ABP(57) is an auxin-binding protein that possesses receptor function. In this study, a protocol for ABP(57) purification was developed on the basis of cross-reactivity shown between ABP(57) and antisera raised against bovine serum albumin, which enabled us to purify ABP(57) with a high yield and to further characterize it. ABP(57) activates plant plasma membrane H(+)-ATPase (PM H(+)-ATPase) via direct interaction. The binding of indole-3-acetic acid (IAA) to the primary binding site on ABP(57) caused a marked increase in the affinity of ABP(57) for PM H(+)-ATPase, which was accompanied by a change in ABP(57) conformation. Meanwhile, additional IAA binding to the secondary site on ABP(57) nullified the initial effect without inducing further conformational change. When ABP(57) with IAA occupying only the primary site interacted with PM H(+)-ATPase, no IAA could access the secondary site. These results suggest that IAA-induced biphasic alteration in the affinity of ABP(57) for PM H(+)-ATPase correlates with a bell-shaped dose response of the enzyme to IAA. There is also a possibility that, whereas the stimulation phase of the response is associated with a conformational change of ABP(57), the destimulation phase probably results from hindrance arising directly from the presence of IAA at the secondary site.

Isotypes of anti-beta2-glycoprotein I antibodies: association with thrombosis in patients with systemic lupus erythematosus

OBJECTIVE

To evaluate the association between isotypes of anti-beta2-glycoprotein I antibodies (anti-beta2-GPI) and thrombosis and to identify antiphospholipid antibodies (aPL) that are most associated with thrombosis in patients with systemic lupus erythematosus (SLE).

METHODS

IgG anticardiolipin antibody (aCL) and isotypes of anti-beta2-GPI were measured by ELISA, and clinical evidence of thrombosis was analyzed in 270 patients with SLE.

RESULTS

IgG, IgM, and IgA anti-beta2-GPI were positive in 38.1, 13.7, and 34.8% of patients, respectively. Patients with a history of thrombosis were significantly more likely to have lupus anticoagulant (LAC), IgG aCL, and the 3 anti-beta2-GPI isotypes. Arterial thrombosis was associated with the presence of IgG aCL and the 3 anti-beta2-GPI isotypes, whereas venous thrombosis was associated with LAC, IgG aCL, and IgA anti-beta2-GPI. In stepwise multivariate logistic regression analysis, the variable that was associated with thrombosis was IgA anti-beta2-GPI. The occurrence of arterial thrombosis was associated with IgG aCL and that of venous thrombosis was related to IgA anti-beta2-GPI in stepwise multivariate analysis. The IgG, IgM, and IgA anti-beta2-GPI titers were closely correlated with IgG aCL titers. The IgA anti-beta2-GPI titers were also significantly correlated with those of IgG and IgM anti-beta2-GPI.

CONCLUSION

The results suggest that anti-beta2-GPI isotypes are related to the occurrence of thrombosis, and measurements of IgA anti-beta2-GPI may be useful for predicting thrombotic episodes in patients with SLE.

Intramedullary tuberculosis manifested as Brown-Sequard syndrome in a patient with systemic lupus erythematosus

A 25-year-old girl presented with progressive deterioration of right side weakness with decreased sensation on the left trunk. She had been treated with high dose steroid due to autoimmune thrombocytopenia for 2 months. Clinical, laboratory and immunologic studies revealed that she had systemic lupus erythematosus (SLE), MRI of spinal cord showed marginal contrast enhancing and fluid containing mass in the cord of the C5-6 level, suggesting intramedullary abscess. She underwent surgery of mass removal with biopsy. The pathologic findings from cord tissues revealed numerous acid fast bacilli (AFB) in necrotic tissues. After surgery and anti-tuberculous treatment, her neurologic symptoms were markedly improved with restoration of right side motor weakness. To our knowledge, this is the first case report of intramedullary tuberculosis in a patient with SLE. Since intramedullary tuberculosis may sometimes mimic neurologic complication of SLE itself, it may pose diagnostic and therapeutic confusion for clinicians. We report a case of spinal cord tuberculosis affecting C5, 6 level which was manifested as Brown-Sequard syndrome in a patient with SLE.

IgG antibodies to type II collagen reflect inflammatory activity in patients with rheumatoid arthritis

OBJECTIVE

To determine the clinical significance of IgG antibodies to type II collagen (CII) and to define any correlation of antibodies to CII with the inflammatory response in patients with rheumatoid arthritis (RA).

METHODS

IgG antibodies to native human type II collagen (IgG anti-CII) were measured in sera and synovial fluid (SF) from patients with RA, patients with osteoarthritis (OA), and healthy controls by an improved ELISA. Demographic, clinical, and laboratory data including tumor necrosis factor-alpha (TNF-alpha) and interleukin 6 (IL-6) levels were also obtained at the time of sampling in patients with RA.

RESULTS

The median level and positivity for circulating IgG anti-CII were higher in patients with RA (n = 297) than patients with OA (n = 34) and healthy controls (n = 50) (p < 0.001). The titers of IgG anti-CII in SF were also higher in RA (n = 45) than in OA (n = 16) (p < 0.001). In paired samples, the levels of IgG anti-CII were significantly higher in SF compared to the sera in patients with RA (n = 45) (p < 0.001), but levels were not different in patients with OA (n = 16). Circulating IgG anti-CII converted from positive to negative in 13 patients (10.7%) and from negative to positive in 18 patients (14.8%) among 122 patients with RA in whom IgG anti-CII were monitored sequentially at a mean interval of 12.2 months. IgG anti-CII positive patients (n = 98) had shorter disease duration (p = 0.04) and less frequent deformity (p = 0.013), and higher median erythrocyte sedimentation rate (ESR) (p = 0.001) and C-reactive protein (CRP) (p < 0.001) than IgG anti-CII negative patients (n = 120). The levels of IgG anti-CII correlated with CRP (r = 0.270) and ESR (r = 0.253). CRP decreased significantly in patients (n = 13) who converted from IgG anti-CII positive to negative (p = 0.013). IgG anti-CII positive patients (n = 40) had higher levels of TNF-alpha and IL-6 than negative patients (n = 40) (p < 0.001). Levels of IgG anti-CII correlated well with TNF-alpha (r = 0.617) and IL-6 (r = 0.347).

CONCLUSION

Increased IgG anti-CII in sera and SF in RA correlated directly with acute phase reactants and the proinflammatory cytokines TNF-alpha and IL-6. Our data suggest that IgG anti-CII could reflect inflammatory activity with a potential to destroy cartilage in the early stages of RA.

Divergent effect of cyclosporine on Th1/Th2 type cytokines in patients with severe, refractory rheumatoid arthritis

OBJECTIVE

To investigate the effect of cyclosporine on cytokine production, especially on T helper 1 (Th1) and T helper 2 (Th2) type cytokines, in patients with rheumatoid arthritis (RA).

METHODS

A 16 week randomized, double blind, placebo controlled study of cyclosporine (2.5 to 4 mg/kg/day) was conducted in 40 patients with severe, refractory RA who had residual inflammation and disability despite partial responses to prior maximal tolerated dose of methotrexate (MTX; < 15 mg/week) and low dose prednisone (< 10 mg/day). Clinical and laboratory variables, and circulating levels of interleukin 2 (IL-2), IL-4, IL-10, IL-12, tumor necrosis factor-alpha (TNF-alpha), and interferon-gamma (IFN-gamma) measured by ELISA were compared between patients (cyclosporine group) treated with cyclosporine plus MTX and those (placebo group) treated with placebo plus MTX at entry and at 16 weeks.

RESULTS

At 16 weeks, the cyclosporine group (n = 17), compared with the placebo group (n = 17), had greater decreases in tender joints, swollen joints, patient global assessment, patient self-assessed disability, and C-reactive protein, as well as having more patients with > 20% improvement. Comparison of circulating cytokines at entry and at 16 weeks showed significant decreases of IL-2 (median -61 vs 7 pg/ml; p = 0.004) ("+" denotes increase, "-" denotes decrease), IL-12 (median -313 vs -14 pg/ml; p = 0.002), TNF-alpha (median -55 vs 5 pg/ml; p < 0.001), and IFN-gamma (median -21 vs 5 pg/ml; p = 0.003), and a significant increase of IL-10 (median 55 vs -12 pg/ml; p < 0.001) in the cyclosporine group compared with the placebo group. The degree of IL-10 increases correlated strongly with the degree of IL-12 decreases in the cyclosporine group (r = 0.572, p = 0.016). However, there was no change in circulating IL-4 between the 2 groups. Within the cyclosporine group, the improved patients (n = 10) compared to the non-improved patients (n = 7) had a greater increase in circulating IL-10 (median 172.0 vs 85.2%; p = 0.01). The rate of increase of IL-10 strongly correlated with the rate of improvement of joint scores (r = 0.718, p = 0.001) after administration of cyclosporine.

CONCLUSION

Our results suggest that the therapeutic effect of cyclosporine is achieved by correcting a Th1/Th2 imbalance (a shift of Th1 type to Th2 type), which may be involved in the pathogenesis of RA; and that circulating IL-10 is useful to assess the clinical improvements in patients with RA after administration of cyclosporine.

Systemic mononuclear inflammatory vasculopathy associated with Sjögren's syndrome in a patient with primary biliary cirrhosis

We report a 46-year-old woman with primary biliary cirrhosis (PBC) presenting with Sjögren's syndrome and systemic mononuclear inflammatory vasculopathy. Biopsy specimens of sural nerve showed findings consistent with vasculitic neuropathy. Perivascular inflammatory mononuclear cell infiltration was observed on muscle biopsy specimen. The findings of abdominal computed tomography and brain magnetic resonance imaging were suggestive of vasculitis. Clinical manifestations and radiologic findings were improved after high dose prednisolone therapy.

Urinary bladder involvement in patients with systemic lupus erythematosus: with review of the literature

OBJECTIVES

To investigate the etiologies of urinary bladder involvement in patients with systemic lupus erythematosus (SLE), the clinicoradiologic features of gastrointestinal tract manifestations and clinical outcomes in patients with lupus cystitis accompanied by gastrointestinal manifestations.

METHODS

We conducted a retrospective chart review on 413 patients with SLE. Patients were selected for review on the basis of lower urinary tract symptoms including urinary frequency, urgency and urinary incontinence. Radiologic studies were analyzed in patients with lupus cystitis.

RESULTS

Ten consecutive patients, complicated with lower urinary tract symptoms, were identified. Underlying etiologies were as follows: lupus cystitis in five, neurogenic dysfunction secondary to transverse myelitis in three, cyclophosphamide-induced cystitis in one and tuberculous cystitis in one patient. All patients with lupus cystitis showed gastrointestinal manifestations, such as abdominal pain, nausea, vomiting and/or diarrhea during the periods of cystitis symptoms. In all patients with lupus cystitis, paralytic ileus was demonstrated on plain abdominal X-ray and ascites, bilateral hydroureteronephrosis and thickened bladder wall were identified on abdominal ultrasound or CT. Abdominal CT revealed bowel wall thickening in four of the five patients. The main sites of thickened bowel on abdominal CT were territory supplied by superior mesenteric artery. Two of five patients with lupus cystitis expired during the follow-up period.

CONCLUSION

Diverse etiologies may cause lower urinary tract symptoms in patients with SLE. Lupus cystitis is strongly associated with gastrointestinal involvement and abdominal CT can be a useful radiologic tool to investigate the gastrointestinal tract involvement in patients with lupus cystitis.

Enhanced T cell proliferative response to type II collagen and synthetic peptide CII (255-274) in patients with rheumatoid arthritis

OBJECTIVE

To determine the presence of specific immune recognition of type II collagen (CII) and its immunodominant epitope CII (255-274) in patients with rheumatoid arthritis (RA).

METHODS

T cell proliferative responses to bovine CII and a synthetic peptide encompassing CII (255-274) in peripheral blood mononuclear cells (PBMC) and synovial fluid mononuclear cells (SFMC) from RA patients, and in PBMC from osteoarthritis (OA) patients and healthy controls were assayed by mixed lymphocyte culture.

RESULTS

The stimulation index (SI) and the number of positive (SI > or = 2) T cell responses to CII were higher in RA patients (n = 106) than in OA patients (n = 26) and healthy controls (n = 34). T cell responses to CII (255-274) were also enhanced in RA patients and correlated well with those to CII. In SFMC, positive responses to CII or CII (255-274) were detected in 61.9% of 42 RA patients. T cell responses to CII in SFMC were stronger and more prevalent than peripheral responses. The SI and positive responses to CII were higher in early RA than in late RA. Levels of IgG antibodies to CII in synovial fluid inversely correlated with T cell responses to CII.

CONCLUSION

T cell responses to CII or CII (255-274) were enhanced in RA, especially in early disease. Synthetic peptide CII (255-274), as well as native CII, could be recognized as immunogenic antigens by T cells, particularly in the synovial fluid. These observations suggest that CII-reactive T cells play an important role in the pathogenesis of RA. Peripheral tolerance induction using CII (255-274) might be useful in the treatment of RA.

Adult respiratory distress syndrome in systemic lupus erythematosus: causes and prognostic factors: a single center, retrospective study

OBJECTIVES

To determine the causes and prognostic factors of Adult Respiratory Distress Syndrome (ARDS) in patients with systemic lupus erythematosus (SLE).

METHODS

Among 544 Korean SLE patients, who were followed in the Lupus Clinic of the Catholic Medical Center from 1993 to 1997, patients diagnosed as ARDS were examined retrospectively. During the study period, non-SLE patients with ARDS were investigated and then compared to SLE patients with ARDS in terms of clinical variables.

RESULTS

Nineteen patients with SLE were revealed to have a history of ARDS (3.5%) and 13 (68.4%) of 19 patients died. Death related to ARDS was found in 34.2% of all deaths (n=38) from SLE during the study period. The frequency and causes of ARDS were as follows; 9 sepsis or bacteremia (47.4%), 2 miliary tuberculosis (10.5%), 2 invasive pulmonary aspergillosis (10. 5%), 2 acute pulmonary alveolar hemorrhage syndrome (10.5%), 1 acute lupus pneumonitis (5.3%), 1 massive hemorrhage due to placenta previa (5.3%), 1 aspiration pneumonitis (5.3%), 1 disseminated intravascular coagulation associated with systemic vasculitis (5.3%). The main organisms in sepsis were gram negative bacilli (61.5%) The median steroid dose administered 1 month before ARDS was significantly higher in patients (n=13) with infectious ARDS compared to those (n=6) with ARDS due to other causes (P=0.038). Comparison of the laboratory and clinical variables between the survivors (n=6) and the deceased (n=13) showed that the survivors had lower SLAM indices at presentation (P=0.004) and APACHE (Acute Physiology, Age, Chronic Health Evaluation) III scores within 24 h after diagnosis of ARDS (P=0.024) than the deceased. The APACHE III scores correlated well with the SLAM indices (r=0.615, P=0.007). Non-SLE patients with ARDS during the study period were selected for comparison to SLE patients with ARDS. Age at the onset of ARDS was younger in SLE (n=19) compared to non-SLE (n=190) (P<0.001). Duration from ARDS onset to death was shorter in SLE patients (P<0. 001). The mortality from ARDS tended to be higher in SLE patients (P=NS). The first-day APACHE III score was significantly higher in deceased SLE patients (n=13) compared to deceased non-SLE patients (n=105) (P=0.001).

CONCLUSIONS

ARDS was a common premortem event of SLE and showed a high fatality rate in SLE. The most common cause of ARDS in Korean patients with SLE was sepsis by gram negative bacilli. ARDS in SLE developed at a younger age, and progressed more rapidly compared to ARDS in general. The SLAM index and APACHE III score could be useful to predict the prognosis of ARDS in SLE.

Causes of death in Korean patients with systemic lupus erythematosus: a single center retrospective study

OBJECTIVE

To determine the causes of death in Korean patients with systemic lupus erythematosus (SLE).

METHODS

We evaluated retrospectively Korean SLE patients who were monitored in the Center for Rheumatic Disease in Kang-Nam St. Mary's Hospital from 1993 to 1997 and who died.

RESULTS

Forty-three (7.9%) of 544 patients died. Comparison of demographics and disease activity indices between the deceased and the survivors showed that the age was older and C3 at presentation was lower in the deceased (n = 40) than the survivors (n = 453) (age: 33.8 +/- 13.6 versus 28.3 +/- 10.6 years, p = 0.02, C3: 36.8 +/- 21.4 versus 49.7 +/- 20.8 mg/dl, p = 0.03). Among 40 patients who died, the frequency and causes of death were as follows: 13 from infection (32.5%), 10 SLE-related factors (25.0%), 6 pulmonary hypertension (15.0%), 4 cerebrovascular accidents (10.0%), and 3 thrombotic thrombocytopenic purpura (7.5%). The majority of the SLE-related deaths were non-renal in origin, including 3 cerebral nervous system disease, 2 TTP, 2 acute pulmonary hemorrhage syndrome, 1 acute myocarditis, and 1 multi-system illness. SLE-related renal causes were responsible for only death. The major organisms of infection were gram negative bacilli (69.2%), primarily manifesting as sepsis or bacteremia (76.9%). The patients (n = 13) who died from infection had lower levels of complement and higher levels of anti-ds DNA antibody at presentation than those (n = 27) who died from the other causes (C3: 24.7 +/- 17.8 versus 41.7 +/- 21.5 mg/dl, p = 0.02, anti-dsDNA antibody: 68.0 +/- 73.5 versus 27.0 +/- 35.3 IU, p = 0.04). The mean steroid dose being administered one month before death was also higher in the patients who died of infection (30.5 +/- 15.2 versus 15.2 +/- 7.7 mg/day, p = 0.03). Patients who died of pulmonary hypertension, the third most common cause of mortality, showed extremely high pulmonary pressures at the initial diagnosis, with a short interval to death, and had less major organ involvement at death. There were no deaths due to coronary heart disease or neoplasm in this cohort.

CONCLUSION

The most common cause of death in 544 Korean lupus patients was infection, mainly manifesting as gram negative bacterial sepsis. SLE-related factors (mostly non-renal) were the next most frequent cause. Death from infection was associated with higher disease activity at presentation and a higher dose of steroid used previously. Death due to pulmonary hypertension was common, whereas death due to coronary heart disease was absent.

A case of sternal insufficiency fracture

We report a case of insufficiency fracture of the sternum in a 70-year-old female patient with a review of the literature. She complained of sudden onset chest pain and aggravating dyspnea. She has been managed with corticosteroid due to chronic obstructive pulmonary disease for 15 years. Diagnosis of sternal insufficiency fracture presented with thoracic kyphosis was made on the basis of absence of trauma history, radiologic findings of lateral chest radiograph, bone scintigraphy and chest computed tomography. Thoracic kyphosis and osteoporosis secondary to menopause, corticosteroid therapy and limited mobility due to chronic obstructive pulmonary disease were considered as predisposing factors of the sternal insufficiency fracture in this patient.

CT features of systemic lupus erythematosus in patients with acute abdominal pain: emphasis on ischemic bowel disease

PURPOSE

To evaluate the computed tomographic (CT) features of systemic lupus erythematosus (SLE) in patients with acute abdominal pain. Special emphasis was placed on the analysis of ischemic bowel disease.

MATERIALS AND METHODS

The authors retrospectively reviewed the images from 39 abdominal CT examinations performed in 33 patients with SLE and acute abdominal pain. Images were evaluated for bowel wall changes, mesenteric changes, fluid collection, retroperitoneal lymphadenopathy, peritoneal enhancement, and hepatomegaly as well as for changes in other abdominal organs. Ischemic bowel disease was diagnosed if at least three of the following signs were seen: bowel wall thickening, target sign, dilatation of intestinal segments, engorgement of mesenteric vessels, and increased attenuation of mesenteric fat.

RESULTS

Thirty-one (79%) of the 39 examinations had CT findings diagnostic of ischemic bowel disease, including symmetric bowel wall thickening (n = 29), target sign (n = 26), and mesenteric vascular engorgement and haziness (n = 31). In 24 cases, bowel wall thickening was multifocal, with variable length, and did not appear to be confined to a single vascular territory.

CONCLUSION

The most common CT finding in patients with SLE and acute abdominal pain is ischemic bowel disease. CT is useful for detecting the primary cause of gastrointestinal symptoms, planning treatment, and monitoring for infarction or perforation.

Synthesis and biological activity of KCB-328 and its analogues: novel class III antiarrhythmic agents with little reverse frequency dependence

A series of 3,4-dimethoxyphenethylamine derivatives was prepared, and their prolongation effects on effective refractory period of contractile response (ERPc) and action potential duration (APD) in isolated guinea-pig papillary muscles at 1 Hz and 3 Hz were examined. SAR studies led to the identification of KCB-328 (51) which is a novel class III antiarrhythmic agent with little reverse frequency dependence.

Hyperimmunoglobulin E-recurrent infection syndrome in a patient with juvenile dermatomyositis

A 13-year-old girl presented with multiple skin abscesses. She was diagnosed as having juvenile dermatomyositis (DM) at the age of 7 years. She had suffered from recurrent skin infections, atypical pruritic dermatitis and pneumonia since the age of 8 years. Bacteriologic and fungal cultures for skin abscesses and oral mucosa were positive S. aureus and C. albicans, respectively. Chemotactic defect in peripheral blood neutrophils was observed. The level of serum IgE was markedly elevated, and anti-S.aureus specific IgE was found. A diagnosis of hyperimmunoglobulin E-recurrent infection syndrome (HIE) was made and she was successfully treated with surgical drainage and antibiotics. To our knowledge, this is the first case report of HIE in a patient with juvenile dermatomyositis.

Effect of complete and partial bilateral lesions of the deep cerebellar nuclei on amygdaloid kindling in rats

PURPOSE

The roles of the deep cerebellar nuclei in epileptogenesis and seizure expression are not well defined. To determine their properties, we examined the effects of lesions to the dentate, fastigial, and interpositus nuclei in adult rats that were electrically kindled in the amygdaloid complex. Changes in afterdischarge duration (ADD) as well as the expression and progression of behavioral seizures to fully generalized tonic-clonic convulsions (stage 5) were assessed.

METHODS

Fifty rats first underwent bilateral electrolytic lesions of either the dentate, fastigial, or interpositus nuclei. After a 7-day recovery period, they were kindled daily until they manifested two stage 5 convulsions. Careful histological examination was used to determine lesion extent.

RESULTS

When the dentate or fastigial nucleus was completely destroyed on the side contralateral to the stimulated amygdala, fewer stimulations were required to produce stage 5 seizures and latencies to the expression of forelimb clonus were shorter, as were ADD. On the other hand, when the dentate or fastigial nucleus was only partly obliterated on the contralateral side, more stimulations were required to produce stage 5 seizures and ADD was longer. Neither complete nor partial lesions of the interpositus nuclei had any effect on the number of stimulations to reach a stage 5 seizure, latency to the expression of clonus, or ADD.

CONCLUSIONS

Our findings suggest that the dentate and fastigial nuclei, but not the interpositus nuclei, may normally retard epileptogenesis and inhibit clonic behaviors, but paradoxically may facilitate ADD.

Bronchiolitis obliterans organizing pneumonia as an initial manifestation in patients with systemic lupus erythematosus

Diverse pleuropulmonary manifestations including diaphragmatic dysfunction, pleural effusion, acute lupus pneumonitis, pulmonary hemorrhage, pulmonary hypertension, and diffuse interstitial lung disease have been described in patients with systemic lupus erythematosus (SLE). Bronchiolitis obliterans organizing pneumonia (BOOP) as an initial manifestation of SLE is rarely reported. We describe 2 patients who had SLE concurrent with the onset of BOOP. Their respiratory symptoms, followup pulmonary function tests, and radiologic findings showed much improvement after steroid therapy.

Central apnea and acute cardiac ischemia in a sheep model of epileptic sudden death

The etiology of sudden death in patients with epilepsy remains unclear. Previous studies in a well-established sheep model of status epilepticus showed that more than one-third of the unsedated animals died within 5 minutes of seizure onset due to hypoventilation. The relative contributions of airway obstruction and central hypoventilation could not be determined because airway flow and respiratory effort were not monitored. In this study, status epilepticus was induced in unsedated sheep with tracheostomies monitored by electrocardiography, electroencephalography, arterial line, serial blood gases, and airway flowmeter. All 8 animals demonstrated central apnea and hypoventilation, which resulted in the death of 1 and contributed to the death of another. A third animal died of acute heart failure within 2 minutes of seizure onset, accompanied by a large septal myocardial hemorrhage, contraction bands, and signs of global cardiac ischemia. More subtle contraction bands, subendocardial hemorrhage, and signs of acute myocardial ischemia were seen in other animals as well, none of which died of cardiac causes. Malignant arrhythmia was not seen in any of the sheep. Central hypoventilation and apnea accompany generalized status epilepticus and may be an important cause of sudden death in epileptics. Acute cardiac failure may also be a cause of epileptic sudden death.

Decreased tumour necrosis factor-beta production in TNFB*2 homozygote: an important predisposing factor of lupus nephritis in Koreans

Low TNF production and its association with TNF gene restriction fragment length polymorphism (RFLP) was demonstrated in (NZW/NZB) F1 mice. However, little is known about the significance of TNF production in association with TNF gene polymorphism in human SLE. This study was designed to evaluate the role of TNF production of peripheral blood mononuclear cells (PBMC) and its association with TNFB gene polymorphism in SLE, particularly lupus nephritis. TNFB gene polymorphism was defined by PCR-NcoI RFLP. TNF productions of phytohemagglutinin (PHA)-stimulated PBMC and T cells were examined by bioassay using L929 cell line and ELISA. The PBMC stimulated by PHA from patients with SLE (n = 60) tended to secrete less amounts of TNF by bioassay (1032 +/- 184 pg/ml vs 1524 +/- 224 pg/ml, P = 0.094), and TNF-beta by ELISA (P = 0.0082) than that from normal controls (n = 38). The low TNF-alpha producer was more frequent in nephritis than non-nephritis (34.4% vs 7.1% respectively, P < 0.01). TNF-beta also revealed similar results (53.1% vs 21.4%, P < 0.05). In SLE, mean production of TNF-beta was decreased in TNFB*2 homozygote (n = 18) than that in TNFB*1 homozygote (n = 9) (1126.3 +/- 145 pg/ml) vs 642 +/- 118.4 pg/ml, respectively, P = 0.021), whereas TNF-alpha production showed little difference between the two groups (710.1 +/- 56.4 vs 542.4 +/- 71.1 pg/ml, respectively, P = 0.149). Our results demonstrate that decreased TNF production of PBMC, which was significantly associated with TNFB*2 homozygosity, could be an important predisposing factor of lupus nephritis in Koreans.