AIDS and oropharyngeal candidiasis

Oropharyngeal candidiasis occurred in a previously healthy young Israeli homosexual male. Additional symptoms included persistent diarrhea, weight loss, fever, generalized lymphadenopathy and peripheral neuropathy. Immunologic studies revealed lymphopenia with reversed T-helper/T-suppressor cells ratio and antibodies to human immunodeficiency virus, all compatible with the diagnosis of subclinical AIDS. Repeated courses of antimonilial treatment failed to eradicate the oropharyngeal lesions. The clinical picture of AIDS, particularly its oral manifestations, is described. The diagnostic and prognostic implications of oropharyngeal candidiasis as a presenting sign of the disease are discussed. In addition, precautionary measures that should be taken when treating persons infected with HIV are described.

Atypical auricular pyoderma gangrenosum simulating fungal infection

We describe a patient with a highly unusual appearance of pyoderma gangrenosum. The pyoderma was located on the auricular region and preceded other manifestations of inflammatory bowel disease by 11 years. There was no correlation between the course of the pyoderma and the clinical activity of the associated bowel disease. Mycotic superinfections masked and delayed the diagnosis in our patient for several years. Only when typical pyoderma gangrenosum lesions developed on the legs at the site of trauma and responded dramatically to systemic corticosteroids was the correct diagnosis established. Pyoderma gangrenosum with secondary fungal infection was thus distinguished from deep ulcerated skin fungal infection simulating pyoderma.

Hepatitis during measles in young adults: possible role of antipyretic drugs

Fifty-six per cent of 118 young adults observed during a recent measles epidemic had some disturbance on liver function tests. Five per cent developed overt jaundice. Patients treated for fever with paracetamol were found to have significantly higher rates of transaminase impairment compared to those treated with dipyrone. Sixty-five and 58% of patients given paracetamol had elevated ALT and AST levels, respectively. Only 15% of patients given dipyrone had elevated levels of these two enzymes (p less than 0.01 for ALT and p less than 0.02 for AST). The mean levels of transaminases and bilirubin in the paracetamol-treated patients were significantly higher than those found in the dipyrone-treated patients [92 +/- 86 vs. 42 +/- 49 IU (p less than 0.02) for AST and 12 +/- 6.0 vs. 7.0 +/- 2.0 mumoles per liter (p less than 0.01) for bilirubin]. The cumulative dose of paracetamol in those who had impaired liver function was higher than that ingested by patients who did not develop liver damage, although still within the usual therapeutic range [11.6 +/- 5.8 vs. 7.6 +/- 4.2 gm (p = 0.02)]. The possible ways in which measles infection and paracetamol in combination can lead to hepatic damage are discussed.

Multicentric Castleman's disease associated with rheumatoid arthritis: a possible role of hepatitis B antigen

A patient with seropositive rheumatoid arthritis and a carrier of hepatitis B surface antigen developed angiofollicular hyperplasia (multicentric Castleman's disease). The hepatitis B virus and the rheumatoid factor may have had a role in the aetiology of this lymphatic disorder. The development of Castleman's disease in association with these factors may provide another clue supporting the reactive nature of this disease.

Measles: clinical and laboratory observations in young adults during an epidemic

We describe the spectrum of clinical and laboratory findings in 130 young nonvaccinated adults who had measles during an epidemic, and give special emphasis to liver involvement. The data from these cases are compared to those of other selected groups of hospitalized young adults. Since measles seems to cause severe morbidity in adults, active measures should be taken to identify and vaccinate vulnerable nonimmunized individuals.

Overload of iron in the skin of patients with varicose ulcers. Possible contributing role of iron accumulation in progression of the disease

The brown pigmentation of the skin associated with venous ulceration is caused by increased local iron deposition. Diagnostic x-ray spectrometry, a method based on x-ray fluorescence analysis, was used for the noninvasive determination of iron levels in the skin of patients with venous ulceration. The mean (+/- SEM) iron concentration in the skin around the venous ulcer was elevated, compared with control values of nonulcerated skin (250 +/- 54 vs 128 +/- 39 micrograms) and compared with normal skin from the forearm (250 +/- 54 vs 14 +/- 2.5 micrograms). These data suggest that dermal iron deposition may not be an incidental by-product of increased venous pressure, but may actively perpetuate tissue damage in venous ulcerations.

Extent of measles hepatitis in various ages

To assess extent of hepatic involvement in measles, we evaluated prospectively 144 patients (ages 0.2 to 43 years) during an outbreak. Liver function parameters (AST, ALT, serum gamma-glutamyl transpeptidase and bilirubin) were determined on presentation and at 2 and 4 weeks. The study comprised 52 pediatric (less than or equal to 14 years) and 92 adult patients. Liver dysfunction was evident quite often (56 to 66%) in adult patients. However, in the pediatric age group, these abnormalities were less frequent and less extensive. Moreover, a significant correlation was noted between age and each of the following parameters: AST (r = 0.61), ALT (r = 0.56) and serum gamma-glutamyl transpeptidase (r = 0.39). In all subjects all parameters normalized after 2 to 4 weeks. The data presented suggest that hepatic dysfunction in measles is probably not rare and is more frequent and more extensive in adults. However, these abnormalities seem to be subclinical, self-limited and probably with no long-term sequelae.

Hypersensitivity reactions to drugs in acquired immunodeficiency syndrome

We describe a patient with AIDS in whom recurrent drug eruption and fever following administration of various unrelated agents developed. Previous drug exposure was uneventful. A possible mechanism for this phenomenon is described.

Right ventricular infarction: unusual electrocardiographic and electrophysiological manifestations

Right ventricular infarction occurs in 19-43% of patients with acute inferior wall infarction (Lorell et al., 1979). Its clinical, hemodynamic, and anatomic features are well known and include associated inferior wall infarction, distended neck veins, clear lung fields, hypotension, and heart block (Cintron et al., 1981; Coma-Canella et al., 1979; Lloyd et al., 1981; Lopez-Sendon et al., 1981; Raabe and Chester, 1978; Rotman et al., 1974). Isolated right ventricular infarction is less frequent and occurs in 2.5-4.6% of autopsy studies of myocardial infarction (Cohn et al., 1974; Erhardt et al., 1976; Wartman and Hellerstein, 1948). This report describes a patient with isolated right ventricular infarction with unusual electrophysiological findings. Her initial electrocardiogram showed atrial escape rhythm with incomplete right bundle-branch block and left posterior hemiblock. Later, she developed atrioventricular (AV) block with supra- and infra-Hisian, "phase 4," conduction defects. The sinus malfunction and high degree AV block persisted over 2 weeks and an atrioventricular sequential pacemaker was implanted. Hymodynamic study showed that her cardiac output was highly dependent on the heart rate and properly timed AV interval, and the pacemaker was programmed accordingly.

Pulmonary valve stenosis and hemophilia A. Report of three cases and discussion of a possible genetic linkage

We treated three unrelated patients with hemophilia A and congenital pulmonary valve stenosis. In two patients, the occurrence of the cardiac malformation was sporadic and in one familial. The coexistence of hemophilia A and pulmonary valve stenosis might suggest a genetic linkage for both disorders. Review of the literature supports the hypothesis that the inheritance of pulmonary valve stenosis is dominant and X-linked.

Cerebral toxoplasmosis complicating bone marrow transplantation

Cerebral toxoplasmosis occurred in a 34-year-old patient with chronic myelogenous leukemia following bone marrow transplantation. The clinical picture included headaches, nuchal rigidity, and right-sided hemiparesis during a course of disseminated cutaneous herpes zoster. The diagnosis of toxoplasmosis was based on serologic evidence and typical computed tomography scan of the brain as well as clinical improvement following specific anti-Toxoplasma treatment. To the best of our knowledge, this is the first report of cerebral toxoplasmosis in Israel.

Skin discoloration in chronic idiopathic thrombocytopenic purpura: detection of local iron deposition by X-ray spectrometry

A forty-six-year-old woman with a 32 years' history of idiopathic thrombocytopenic purpura presented with black-brown discoloration of her lower limbs. Noninvasive diagnostic X-ray spectrometry (DXS) for determination of trace elements in external tissues revealed striking local iron deposition confined to the skin area with the pigmentary changes. Iron deposition in the skin was probably due to recurrent local purpura caused by longstanding bleeding disorder. Hence DXS proved useful in the detection of local iron load and eliminated the need for skin biopsy in this patient with bleeding tendency.

Bioavailability of phenytoin: comparison between three preparations

Crossover studies, following single oral doses given to 19 healthy volunteers were conducted to compare the bioavailability of three phenytoin preparations: DANTOIN and IDANTOIN (Teva, Israel) and EPANUTIN (Parke-Davis, USA). The first has recently replaced the second as the only preparation available in Israel for alleged better bioavailability. The area under the serum concentration time curve (AUCo----48), however, did not significantly differ between preparations, indicating equivalent absorption of the three preparations. These results suggest that no overall adjustments are required when switching from one preparation to another.

Amiodarone-associated hypothyroidism--a possible cause of digoxin intoxication

The problem of a possible interaction between amiodarone and digoxin is still unsettled. We have recently treated two patients with digoxin intoxication who had received amiodarone for eight and 36 months respectively. Both developed extreme bradycardia requiring temporary pacemakers. The presence of hypothyroidism was confirmed in both cases by laboratory data. Judging by present knowledge concerning the interaction between amiodarone, thyroid function, and digoxin, it is suggested that digoxin intoxication was not the result of its direct interaction with amiodarone. The possibility that amiodarone-induced hypothyroidism precipitated digoxin intoxication seems to be more plausible. Prevention of digitalis toxicity in amiodarone-treated patients would therefore require monitoring of thyroid function every three to six months. Frequent monitoring of digitalis blood levels is also indicated in patients with amiodarone associated hypothyroidism. Early detection of hypothyroidism and digitalis intoxication is necessary in view of the severity of the course of the disease.

Immunoglobulin E response during measles

Serum IgE levels were determined in 41 patients with measles infection. 23 patients (56%) had an increased level (greater than 20%) during the acute phase of the disease in comparison with the recovery phase. 14 showed no change, and decreased levels were observed in 4 patients only. In contrast, both IgG and IgA levels decreased or remained unchanged in the majority of the patients during disease activity. The changes in the pattern of serum immunoglobulins during measles might be attributed to selective depletion of T-cell subpopulations.