Dimorphic immunohistochemical staining in ocular sebaceous neoplasms: a useful diagnostic aid

PURPOSE

We studied whether patterns of immunostaining in formalin-fixed, paraffin-embedded tissue could help to distinguish between sebaceous neoplasms of the eyelid and other eyelid neoplasms.

METHODS

We applied antibodies to human milk fat globule-1 (HMFG1), cytokeratins (PKK1 and MNF116), epithelial membrane antigen (EMA) and carcino-embryonic antigen (CEA) to normal eyelid tissue and to a range of sebaceous lesions of the eyelid; these included sebaceous hyperplasia, sebaceous adenoma and sebaceous epithelioma, in addition to well to poorly differentiated sebaceous carcinoma.

RESULTS

The central and peripheral cellular components of normal sebaceous glands and neoplastic sebaceous lesions showed a distinctive dimorphic staining pattern with the antibody panel used. The central foamy 'sebaceous' cells expressed HMFG1 and EMA, but not PKK1 or MNF116, whereas the smaller, peripheral basal and ductal cells expressed PKK1 or MNF116 but not HMFG1 or EMA. CEA expression in sebaceous cells was unhelpful diagnostically.

CONCLUSION

Normal sebaceous glands and all sebaceous neoplasms show a dimorphic cell population that can be identified using a small panel of antibodies on formalin-fixed, paraffin-embedded tissue. This distinctive staining pattern can be assessed retrospectively, even in small biopsies, and largely removes the need for fat stains on frozen sections to differentiate sebaceous lesions from other ocular neoplasms. The results also support the suggestion that ocular sebaceous neoplasms arise from a common stem cell, rather than from either sebaceous or basal/ductal cells.

Effects of prosodic stress and serial position on syllable omission in first words

The authors documented syllable omission in one child's multisyllabic vocabulary from 10 to 20 months of age to evaluate L. Gerken's (1991, 1994a, 1994b) proposal that children organize their productions according to a trochaic metrical (strong-weak) template and omit syllables from target utterances that do not conform to this pattern. The trochaic template hypothesis was not supported by these early productions. Results indicated that the likelihood of producing a target syllable was influenced primarily by the strength of the prosodic stress placed on it and secondarily by its serial order within a word. Over time, the child demonstrated an increasing ability to include syllables with weaker prosodic stress in multisyllabic productions. Omissions became much less common with the onset of 2-word speech.

Fatal Serratia marcescens meningitis and myocarditis in a patient with an indwelling urinary catheter

Serratia marcescens is commonly isolated from the urine of patients with an indwelling urinary catheter and in the absence of symptoms is often regarded as a contaminant. A case of fatal Serratia marcescens septicaemia with meningitis, brain abscesses, and myocarditis discovered at necropsy is described. The patient was an 83 year old man with an indwelling urinary catheter who suffered from several chronic medical conditions and from whose urine Serratia marcescens was isolated at the time of catheterisation. Serratia marcescens can be a virulent pathogen in particular groups of patients and when assessing its significance in catheter urine specimens, consideration should be given to recognised risk factors such as old age, previous antibiotic treatment, and underlying chronic or debilitating disease, even in the absence of clinical symptoms.

Evaluation of a statistically derived decision tree for the cytodiagnosis of fine needle aspirates of the breast (FNAB)

A decision tree for the diagnosis of FNAB was derived from defined human observations using a rule induction method, C4.5 (a derivative of the ID3 algorithm). This algorithm is an implementation of the top-down induction method where the tree is determined iteratively by adding those nodes and branches which maximize the information gain at each step. The tree was derived from a training set of 200 FNAB with known outcome using 10 defined features (from one observer) and patient age. The tree contained a total of seven nodes (six observable features and patient age) with eight endpoints (four benign, four malignant). The tree was applied to a test set of 400 further FNAB with observations from the training observer and produced a sensitivity of 95%, specificity of 93% and a positive predictive value (PPV) of a malignant result of 89%. Four trainee pathologists were given a training session on the observable features and then used the tree to determine outcome in a further 50 FNAB. The observers were blind to clinical details apart from age and the endpoints were coded with letters and not labelled benign or malignant. The results from these observers produced ranges of sensitivity 80-96%, specificity 64-92%, PPV 73-92% and kappa statistics (with known outcome) 0.6-0.8. Reported difficulties in using the tree included estimation of nuclear size. These results were worse than the performance of the observers on a further 50 cases without using the decision tree (sensitivity 80-100%, specificity 72-100%, PPV 78-100%, kappa 0.72-0.92). The original 50 case test set was rerandomized and the four trainee observers made all 10 defined observations on each specimen without using the decision tree; these observations were then used to derive decisions from the tree. The performance from this method was similar to that using selected features from the tree, suggesting that observation of all features together does not improve the reliability of each specific observation. The poor performance of this tree suggests that this methodology may be unsuitable for producing decision support aids for diagnostic or training purposes in this domain.

Effects of sampling interval on peak oxygen consumption in patients evaluated for heart transplantation

BACKGROUND AND METHODS

Peak oxygen consumption is a commonly accepted criterion in patient selection for cardiac transplantation. To determine the effect of various gas exchange sampling intervals on the variability of peak oxygen consumption, 15 consecutive patients evaluated for cardiac transplantation performed maximal treadmill testing using a ramped protocol. Oxygen consumption was measured via breath-by-breath analysis of expired air. Peak oxygen consumption was determined for each test using the following sampling intervals: 60-, 30-, and 15-s averages, eight breath rolling average, and true breath by breath. Variability of the mean peak oxygen consumption for each sample average was compared using analysis of variance on repeated measures.

RESULTS AND CONCLUSIONS

Measures of peak oxygen consumption differed significantly (p<0.001) between sampling averages. A maximum variability of 20% was noted between the largest and smallest averages (13.8+/-4.2 mL/kg/min for 60 s vs 17.3+/-4.2 mL/kg/min for breath by breath). No significant difference was found between the 30-s, 15-s, and eight breath rolling averages (14.2+/-3.7 vs 14.5+/-3.9 vs 14.7+/-4.3 mL/kg/min), respectively. Results of the study suggest (1) the sampling average can have a significant effect on peak oxygen consumption influencing patient selection for transplantation, and (2) sample averages larger than breath by breath but smaller than 60 s be used for determination of peak oxygen consumption.

A production limitation in syllable number: a longitudinal study of one child's early vocabulary

The present paper reports on the phonological form of one child's productive vocabulary from age 0;10 to 1;8 with primary focus on his production of multisyllabic targets. A large percentage of his multisyllabic vocabulary was produced as one syllable until the age of 1;6. This limitation was not due to a tendency to extract only single syllables from the speech stream, but rather due primarily to a limitation on production. While some portion of his one-syllable productions could be interpreted as the result of single syllable extraction, a sizeable portion affirmed that he extracted the target size correctly by his inclusion of first and final target phonemes in his productions (e.g. [po] for piano and [kiz] for candies). The resolution of this limitation coincides with his move toward two-word speech. We conclude that there is a developmental and perhaps maturational limitation in the capacity to carry out the processes underlying word and sentence production.

Improvement of expression and secretion of a fungal xylanase in the rumen bacterium Butyrivibrio fibrisolvens OB156 by manipulation of promoter and signal sequences

Promoters and signal sequences for expression and secretion of a fungal xylanase encoded by a modified Neocallimastix patriciarum xynA cDNA in the rumen bacterium, Butyrivibrio fibrisolvens OB156, were investigated. Successful expression of the fungal xylanase in OB156 was obtained using the putative xylanase promoter from B. fibrisolvens strain 49. Replacing the putative -35 region sequence (TTGCAC) of the xylanase promoter with the sequence TTGACA by mutagenesis reduced the fungal xylanase expression level 4-fold in OB156, indicating that this B. fibrisolvens strain did not efficiently recognise the E. coli consensus -35 sequence. Reduction of the spacer length between the -35 and -10 regions of the xylanase promoter from 18 to 17 base-pairs (bp) considerably increased the expression levels of the fungal enzyme in both E. coli and OB156. Insertion of a pUB110 mob promoter upstream of the xylanase promoter also significantly improved the fungal xylanase expression. Secretion of the fungal xylanase mediated by the alpha-amylase signal peptide from B. fibrisolvens strain H17c was efficient in E. coli, but very poor in OB156. An increase in the hydrophobicity of the signal sequence resulted in a 4-fold increase in the extracellular portion of the fungal xylanase in OB156, indicating marked improvement in xylanase secretion efficiency. The recombinant plasmids and xylanase expression/secretion cassettes were found to be stable in OB156 after prolonged cultivation (100 generations) in the absence of antibiotic selection. These results suggest that the rumen bacterium B. fibrisolvens can be manipulated to produce and secrete a eukaryotic extracellular protein with stable maintenance of the expression cassette in plasmid form.

Experimental evaluation of rodent exclusion methods to reduce hantavirus transmission to humans in rural housing

An experimental assessment of methods to reduce rodent infestations in rural housing was conducted in Yosemite National Park, California, Sequoia/Kings Canyon National Parks, California, and Shenandoah National Park, Virginia. During pretreatment surveys, nearly all (63 of 68) selected units had past or ongoing rodent activity inside. Active infestations were found in 58.8% of the units. Peromyscus spp. represented 91.2% of all animals caught inside housing units. Despite little harborage, rodent activity was common near housing (290 animals/2,254 trap nights). The most common species present was Peromyscus maniculatus (43-50% of all captures). This species was especially frequent (49-87% of Peromyscus captures) around the foundations of housing units. Habitat had little effect on captures. There were 1.8 Peromyscus caught per unit along the foundations of housing in modified rural settings with grass lawns compared with 1.2 Peromyscus caught per unit in sites located in mature woodlands. During autumn of 1994, randomly selected housing units were rodent proofed by sealing openings associated with chases, roof eaves, and attics with insulation and wire mesh. Housing was examined and the fauna was resampled in the spring-summer of 1995. Rodent-proofed houses were infested significantly less often (3 of 28) than control houses (13 of 36) (P = 0.02) and the intensity of infestation was lower in experimental houses (6 versus 23 mice/treatment). More than 25% of the mice trapped inside the houses had been marked outside the houses during the three-day surveys, demonstrating movement of mice adjacent to the buildings into not rodent-proofed housing. As in the previous autumn, most of the animals captured in (98.9%) and along the foundations of the houses (77.5%) were Peromyscus spp. These results demonstrate that Peromyscus frequently invade rural housing but rodent-proofing effectively eliminates or substantially reduces rodent activity.

Temperature-regulated expression of the tac/lacl system for overproduction of a fungal xylanase in Escherichia coli

Temperature-regulated expression of recombinant proteins in the tac promoter (Ptac) system was investigated. Expression levels of fungal xylanase and cellulase from N. patriciarum in E. coli strains containing the natural lacI gene under the control of the Ptac markedly increased with increasing cultivation temperature in the absence of a chemical inducer. The specific activities (units per milligram protein of crude enzyme) of the fungal xylanase and cellulase produced from recombinant E. coli strain pop2136 grown at 42 degrees C were about 4.5 times higher than those of the cells grown at 23 degrees C and were even slightly higher when compared with cells grown in the presence of the inducer isopropyl beta-D-thiogalactopyranoside. The xylanase expression level in the temperature-regulated Ptac system was about 35% of total cellular protein. However, this system can not be applied to E. coli strains containing lacIq, which confers over production of the lac repressor, for high-level expression of recombinant proteins. In comparison with the lambda PL system, the Ptac-based xylanase plasmid in E. coli pop2136 gave a considerably higher specific activity of the xylanase than did the best lambda PL-based construct using the same thermal induction procedure. The high-level expression of the xylanase using the temperature-regulated Ptac system was also obtained in 10-litre fermentation studies using a fed-batch process. These results unambiguously demonstrated that the temperature-modulated Ptac system can be used for overproduction of some non-toxic recombinant proteins.

In situ lymphoproliferation in renal transplant biopsies

A double immunohistochemical labelling procedure in paraffin-embedded renal tissue is reported in which CD3 was targeted as a T cell marker and Ki67 as a marker of cell proliferation. Proliferating and quiescent T cells were unequivocally identified in situ, and their precise location within the kidney was clarified by the use of periodic acid-Schiff counterstaining to outline the basement membranes. Proliferating tubular epithelial cells were also clearly identified. The results showed that T lymphocytes proliferate within the tubular compartment during acute renal allograft rejection. Preliminary evaluation of the method in routine transplant biopsies indicated significant correlations between histologically defined rejection grade and mean intratubular T lymphocytes per tubular cross section and between proliferation of tubular epithelial cells and of intratubular T lymphocytes. The associated tubular epithelial cell proliferation may be a response to local damage.

Inhibition of matrix metalloproteinases by hydroxamates containing heteroatom-based modifications of the P1' group

In this study, structure-based drug design of matrix metalloproteinase inhibitors [human fibroblast collagenase (HFC), human fibroblast stromelysin (HFS), and human neutrophil collagenase (HNC)] was utilized in the development of potent hydroxamates which contain novel, heteroatom-based modifications of the P1' group. A series containing a P1' butyramide group resulted in a nanomolar potent and selective HNC inhibitor as well as a dual HFS/HNC inhibitor. Benzylic ethers with a four- or five-carbon methylene linker in the P1' position also produced nanomolar potent HFS/HNC inhibition and micromolar potent HFC inhibition as expected. Surprisingly, the phenolic ethers of the same overall length as the benzylic ethers showed nanomolar potencies against HFC, as well as HFS and HNC. The potency profile of the phenolic ethers was optimized by structure-activity relationships of the phenolic group and the C-terminal amide. These inhibitors may help elucidate the in vivo roles of matrix metalloproteinases in normal and disease states.

Induction and reversal of long-lived specific unresponsiveness to a T-dependent antigen following CTLA4Ig treatment

We have examined the ability of CTLA4Ig to induce long-lasting Ag-specific tolerance to a T-dependent Ag. Treatment of mice with murine CTLA4Ig following immunization with SRBC induced immune unresponsiveness to SRBC that was only reversible upon repeated Ag exposure. This unresponsiveness was Ag specific, lasted > 90 days, was observed in thymectomized mice, and was maintained even during challenge with another strong T-dependent Ag. A third challenge with SRBC, however, led to an Ab response. Splenic T cells and B cells from unresponsive mice were functional upon transfer to irradiated hosts, indicating that they had been neither depleted nor rendered permanently "tolerant" by CTLA4Ig. The mechanism of immunosuppression by CTLA4Ig was investigated by measuring cytokine transcripts in spleens of immunized mice. CTLA4Ig treatment following primary immunization blocked the induction of IL-2 transcripts in splenic T cells and IL-4 transcripts in both T cells and non-B, non-T cells. Splenocytes from CTLA4Ig-treated, SRBC-unresponsive mice showed altered induction of IL-2 and IL-4 transcripts, but T cells nonetheless became primed for IL-4 mRNA synthesis despite the lack of a measurable Ab response. Anti-IL-4 mAb and human CTLA4Ig were synergistic in their ability to induce unresponsiveness, indicating that incomplete suppression of IL-4 production by CTLA4Ig limited its effectiveness.

Induction and reversal of long-lived specific unresponsiveness to a T-dependent antigen following CTLA4Ig treatment

We have examined the ability of CTLA4Ig to induce long-lasting Ag-specific tolerance to a T-dependent Ag. Treatment of mice with murine CTLA4Ig following immunization with SRBC induced immune unresponsiveness to SRBC that was only reversible upon repeated Ag exposure. This unresponsiveness was Ag specific, lasted &gt; 90 days, was observed in thymectomized mice, and was maintained even during challenge with another strong T-dependent Ag. A third challenge with SRBC, however, led to an Ab response. Splenic T cells and B cells from unresponsive mice were functional upon transfer to irradiated hosts, indicating that they had been neither depleted nor rendered permanently "tolerant" by CTLA4Ig. The mechanism of immunosuppression by CTLA4Ig was investigated by measuring cytokine transcripts in spleens of immunized mice. CTLA4Ig treatment following primary immunization blocked the induction of IL-2 transcripts in splenic T cells and IL-4 transcripts in both T cells and non-B, non-T cells. Splenocytes from CTLA4Ig-treated, SRBC-unresponsive mice showed altered induction of IL-2 and IL-4 transcripts, but T cells nonetheless became primed for IL-4 mRNA synthesis despite the lack of a measurable Ab response. Anti-IL-4 mAb and human CTLA4Ig were synergistic in their ability to induce unresponsiveness, indicating that incomplete suppression of IL-4 production by CTLA4Ig limited its effectiveness.

Modification of a xylanase cDNA isolated from an anaerobic fungus Neocallimastix patriciarum for high-level expression in Escherichia coli

A Neocallimastix patriciarum xylanase cDNA with the core coding sequence essentially identical to xynA was isolated and modified for high-level expression in Escherichia coli. The xylanase cDNA was truncated into individual catalytic domains, which were modified at the N-terminus. These modified xylanases were synthesised as non-fusion proteins under the control of the tac promoter. High-level expression was obtained with the modified domain II construct, accounting for approx. 25% of total cellular protein. However, with the same vector and expression cassette, expression levels of constructs containing domain I or domains I and II fused in tandem were very low. RNA analysis revealed that the striking difference in expression levels of these three constructs was not due to transcription efficiency, but was mainly related to transcript stability. Further analysis of the domain II construct revealed that the high-level expression of the domain II xylanase was largely attributed to the presence of a favourable N-terminal coding sequence, as mutation at the N-terminus of the domain II dramatically reduced the expression level. The modified domain II xylanase produced in E. coli had a specific activity of 1229 U mg-1 protein at pH 7 and 50 degrees C without purification. The availability of a recombinant fungal xylanase with high specific activity and in high yield offers a potentially attractive source of xylanase for industrial applications.

CTLA4Ig treatment ameliorates the lethality of murine graft-versus-host disease across major histocompatibility complex barriers

Graft-versus-host disease (GVHD), a pathological condition associated with BMT, results from activation of donor T lymphocytes by host tissues. CD28 and CTLA-4 are structurally related T cell receptors for members of the B7 (CD80) gene family, which transmit important costimulatory signals for T cell activation in vitro and in vivo. Here we have investigated the effects of CTLA4Ig, a soluble form of CTLA-4, on lethal GVHD in a murine model. Lethal GVHD was induced by transfer of parent C57BL/6 bone marrow and spleen cells into lethally irradiated (C57BL/6 x DBA/2)F1 recipients. Short courses of treatment with CTLA4Ig did not block engraftment, but prolonged survival of BMT recipients even when administration was delayed for 6 days after transplantation. CTLA4Ig-treated survivors of GVHD maintained body weight and did not exhibit visible signs of GVHD. However, treatment regimens that maximally prolonged survival did not detectably prevent T cell-mediated hematological abnormalities associated with GVHD, including pancytopenia and abnormal cellular composition of the spleen. Our data thus show that the lethality of acute GVHD in this model system is more dependent upon CD28/CTLA-4 costimulation than are other GVHD-associated abnormalities, and can be blocked for an extended period by brief treatment with CTLA4Ig.

1.56 A structure of mature truncated human fibroblast collagenase

The X-ray crystal structure of a 19 kDa active fragment of human fibroblast collagenase has been determined by the multiple isomorphous replacement method and refined at 1.56 A resolution to an R-factor of 17.4%. The current structure includes a bound hydroxamate inhibitor, 88 waters and three metal atoms (two zincs and a calcium). The overall topology of the enzyme, comprised of a five stranded beta-sheet and three alpha-helices, is similar to the thermolysin-like metalloproteinases. There are some important differences between the collagenase and thermolysin families of enzymes. The active site zinc ligands are all histidines (His-218, His-222, and His-228). The presence of a second zinc ion in a structural role is a unique feature of the matrix metalloproteinases. The binding properties of the active site cleft are more dependent on the main chain conformation of the enzyme (and substrate) compared with thermolysin. A mechanism of action for peptide cleavage similar to that of thermolysin is proposed for fibroblast collagenase.

Superficial tinea infections

Dermatophytes commonly cause superficial dermatoses, especially in children, but these infections are frequently misdiagnosed as nonfungal disease. Superficial tinea infections can vary widely in appearance, ranging from a single, small, circular lesion with mild erythema and a scaling active border to multiple large areas of marked inflammation with vesicle formation. Therefore, laboratory tests, particularly the potassium hydroxide slide preparation, are often necessary to establish the diagnosis. The culture becomes particularly important if the smear is negative but a superficial dermatosis is strongly suspected. Tinea capitis is frequently diagnosed only by culture. Since many agents are available to treat superficial dermatoses, cost should be an important consideration in the selection of a topical antifungal agent. Oral agents are recommended for scalp and nail infections, as well as extensive body infections. Griseofulvin is the oral agent of choice because of its efficacy and low toxicity.

In a drug discrimination procedure isolation-reared rats generalize to lower doses of cocaine and amphetamine than rats reared in an enriched environment

Rats with different behavioral histories, defined by rearing and housing in either an enriched condition (EC) or an isolation condition (IC), were trained in a two-lever operant procedure to discriminate 5.0 mg/kg cocaine from saline. In cocaine dose-generalization tests, the IC rats exhibited an ED50 (1.01 mg/kg) significantly lower than the EC rats (ED50: 1.55 mg/kg). The cocaine-appropriate responding was emitted when the rats were treated with d-amphetamine, and for the d-amphetamine test doses the ED50 (0.19 mg/kg) was again significantly lower for the IC rats compared to the ECs (ED50: 0.33 mg/kg). These data suggest that IC rats are more sensitive to the stimulus properties of indirect dopaminergic agonists than EC rats and highlight the importance of environmental variables in governing an organism's response to the stimulus properties of abused drugs.

Evaluation of a dual-channel full dynamic range compression system for people with sensorineural hearing loss

This article describes an evaluation of an in the ear hearing aid, which applies fast-acting full dynamic range compression independently in two frequency bands. This can compensate for the loudness recruitment typically associated with sensorineural hearing loss. The crossover frequency between the two bands and the gain and compression ratio in each band are programmable to suit the individual patient. Twenty subjects with moderate sensorineural hearing loss were tested in a counterbalanced order using the aid programmed as a linear amplifier (condition L) and as a two-band compressor (condition C). All subjects were fitted binaurally. Subjects were also tested without hearing aids (condition U) and using the hearing aids that they normally wore (condition Own). Speech intelligibility was measured in quiet at three sound levels (50, 65, and 80 dB SPL), and speech reception thresholds (SRTs) in 12-talker babble were measured under monaurally and binaurally aided conditions, with the speech and babble both coincident and spatially separated. In condition C, speech intelligibility in quiet was high at all sound levels. Speech intelligibility at the two lower levels decreased in condition L, and decreased still further in conditions Own and U. Condition C gave, on average, better speech intelligibility in babble (lower SRTs) than conditions L, Own, or U. The advantage of condition C over condition L varied across subjects and was correlated with the dynamic range for tones at high frequencies; small dynamic ranges were associated with greater benefit from compression. A significant advantage for binaural aiding was found both when the speech and noise were spatially separated and when they were coincident. The binaural advantage was similar for the C and L conditions, indicating that the independent compression at the two ears did not adversely affect the use of binaural cues. Questionnaires on the subjects' experiences with the aids in everyday life indicated that they generally preferred condition C over condition L.

Patient experiences with multiband full dynamic range compression

This investigation compared performance for 18 experienced hearing aid patients with a multiband full dynamic range compression hearing device and their previously worn linear or automatic gain control hearing aids. Performance was evaluated using a variety of clinical tests. These included functional gain and dynamic range measurements, speech recognition, and real ear measurements. Patients rated their performance with the multiband compression device and their previously worn aids on a rating scale pertaining to a variety of real life listening situations. Statistical analysis of data derived from test results shows significantly improved performance on all measures using the multiband compression aid over their conventional aids. Patients rated their performance higher with the compression instrument than with the conventional aids. Differences in performance on clinical tests and subjective patient responses appear to be related to the different signal processing schemes used in the two groups of devices.

Profuse diarrhea after misoprostol use in a patient with a history of Crohn's disease

OBJECTIVE

To report a case of profuse diarrhea after misoprostol use in a patient with a history of Crohn's disease and to discuss the role of eicosanoids in Crohn's disease.

DATA SOURCES

Patient medical records, case reports, review articles identified by MEDLINE, and personal communication with the physician, patient, and manufacturer.

DATA EXTRACTION

From interviews, the manufacturer, and pertinent published sources by one author and reviewed by the others.

DATA SYNTHESIS

A 55-year-old woman presented to clinic complaining of multiple joint pains. Her medical history was significant for peptic ulcer disease, hypertension, and Crohn's disease in remission since May 1989. Her joint pains were treated with ibuprofen 600 mg po qid and misoprostol 200 micrograms po qid (after meals and at bedtime). Following the administration of three doses of ibuprofen and misoprostol, the patient experienced abdominal cramps, pain, and voluminous, watery diarrhea for two days. Upon discontinuation of the ibuprofen and misoprostol, all of her gastrointestinal symptoms resolved within 12 hours. Rechallenge with ibuprofen alone failed to produce a recurrence of symptoms. Enhanced synthesis of intestinal eicosanoids has been demonstrated in Crohn's disease. Misoprostol, a synthetic analog of one of the eicosanoids, could induce a flare-up of Crohn's disease as suggested in this patient.

CONCLUSIONS

Misoprostol should be used with caution in patients with known inflammatory bowel disease.