[Primary angiosarcoma of the heart. A report of a new case and a review of the literature]

The case is presented of a primitive heart angiosarcoma (PHA) in a 53-year-old woman who developed repeated episodes of hemopericardium with cardiac tamponade. A literature review is performed. PHA is the most frequent primitive cardiac tumor. It is usually localized in the right striatum and is accompanied by effusion of pericardium and right heart failure. The diagnosis is usually made late and bidimensional echography is of great value. Treatment is surgical, if possible. Chemotherapy protocols are being used but with obscure prognosis.

Relationship between survival and binding of plant lectins during small intestinal passage and their effectiveness as growth factors

The effects on the small intestine and the growth of rats of six pure plant lectins: PHA (Phaseolus vulgaris); SBL (Glycine maxima); SNA-I and SNA-II (Sambucus nigra); GNA (Galanthus nivalis) and VFL (Vicia faba), covering most sugar specificities found in nature, were studied in vivo. Variable amounts, 25% (VFL) to 100% (PHA, GNA) of the lectins administered intragastrically, remained in immunochemically intact form in the small intestine after 1 h. All lectins, except GNA, showed binding to the brush border on first exposure, although this was slight with VFL. Thus, binding to the gut wall was not obligatory for resistance to proteolysis. Exposure of rats to lectins, except VFL, for 10 days, retarded their growth but induced hyperplastic growth of their small intestine. The two activities were directly related. PHA and SNA-II, whose intestinal binding and endocytosis was appreciable after 10 days of feeding the rats with diets containing these lectins and similar to that found on acute (1 h) exposure, were powerful growth factors for the small intestine. GNA, which did not bind at the start but was reactive after 10 days, and SNA-I, which behaved in the opposite way, induced changes in receptor expression in the gut. As they were bound to the brush border transiently, they were less effective growth factors. VFL was not bound or endocytosed, was non-toxic and did not promote gut growth.

Psychiatric morbidity among medical out-patients in Spain: a case for new methods of classification

A study was carried out to document the psychiatric disturbances among consecutive first-day attenders to an internal medicine out-patient clinic in Spain. Subjects were interviewed in three different stages using standardized procedures, basically the Clinical Interview Schedule (CIS). As hypothesized, the rate of disturbances was high (46.9%) and their classification with ICD-9 criteria was problematic. Minor affective disturbances were the most common diagnoses; the distribution of anxiety and depression scores followed the 'two correlated dimensions' model. The psychopathological differences between 'cases' and 'non-cases' seemed quantitative rather than qualitative. Absence of organicity, a pattern of multiple consultations and social problems were more frequent among the 'cases'. These data support the use of multiaxial classificatory systems. Ten supervised interviews significantly improved the internist recognition of 'cases' and the suggestion is made that a single routine question about the patients' mood would sensibly improve the detection rates.

Skin window immune response to normal human IgG in patients with rheumatoid arthritis and acute poststreptococcal glomerulonephritis

The skin window technic was utilized to determine the reactivity of patients with rheumatoid arthritis (RA) and acute poststreptococcal glomerulonephritis (APSGN) to human IgG (H-IgG). The response to H-IgG was compared in nine patients with RA, 20 patients with APSGN, and 10 normal individuals. All subjects were tested concomitantly with the saline solution used as solvent for H-IgG. The normal controls and five patients were challenged, in addition, with diphtheria-tetanus-pertussis antigen (DPT) to which they had previous prophylactic exposure. The following results were obtained: 1) Four patients with RA and nine patients with APSGN responded with increased lymphocyte migration (more than 2 SD above the normal mean level) at nine and 12 hours. 2) The mean estimated immunogenic lymphocytosis (calculated subtracting the lymphocyte counts of the saline skin windows) of both patient groups was significantly higher than that of controls at the same time intervals. 3) The response of normal individuals and patients to DPT was comparable in time of appearance and intensity to the response of patients to H-IgG. Our studies that patients with RA and APSGN respond to H-IgG in a manner comparable to that observed with a known antigenic stimulus and support a clinical role for antiglobulin reactivity.

Long-term prognosis of epidemic poststreptococcal glomerulonephritis in Maracaibo: follow-up studies 11-12 years after the acute episode

In 1968 there was an epidemic outbreak of acute poststreptococcal glomerulonephritis in Maracaibo during which 384 cases were hospitalized. Of these cases, 120 were recalled in 1974 and the results of their investigations were reported. The present work concerns 71 patients from this group followed for 11-12 years and studied with measurement of creatinine clearance (CCr), protein excretion and urine sediment analyses. Measurements of serum immunoglobulins, cryoglobulins, C3 levels and rheumatoid factor titers were also made. One patient developed uremia and is in chronic dialysis. Persistent abnormalities were detected in 21.1% of the patients. Depressed creatinine clearance was found in 12.6% of the patients and proteinuria (0.5-2.0 g/day) in 11.2%. Microscopic hematuria occurred in 4.1%. Only 2 patients wer hypertensive. Transient serological abnormalities were seen in 36 patients: elevated IgG levels in 27, serum cryoglobulins in 17 and a low C3 level in 1 patient. Cryoglobulins were found in 50% of the patients with abnormal renal findings and in 22.9% of the patients with normal renal function and urine sediment. Children (at the time of the epidemic) had urinary abnormalities less frequently (16.1%) than did adults (55.5%). Of 9 patients who had been found abnormal five years before, 3 were improved or normal, 3 were stable and 3 showed progressive disease. our studies indicate that uremia is rare in the first decade after epidemic poststeptococcal glomerulonephritis. Nevertheless, the increasing incidence of depressed renal function dictates the need for continued follow-up of this group of patients.

Attack rate of poststreptococcal nephritis in families. A prospective study

Twenty-two families comprising 141 first-degree relatives (42 parents and 99 siblings) were studied prospectively after the appearance in the family of an index case with acute poststreptococcal glomerulonephritis (APSGN). There was no epidemic when the studies were conducted. Families were observed weekly for 4-6 weeks after the appearance of the index case, and at least every 6 months thereafter for 1-3 years. At each examination all members of the family gave a history and had a physical examination, urine analysis, and appropriate cultures; antistreptococcal antibody titres and serum C3 were determined. 33 parents and 95 siblings showed changes in antistreptococcal antibody titres suggestive of infection during or shortly before the period of weekly observation. Group A streptococci of various M and T types were isolated from 17 individuals in 14 families. 25 cases of clincal APSGN (including 22 index cases) and 12 cases of asymptomatic APSGN were detected. The results indicate that within families the streptococci responsible for nonepidemic APSGN are very infectious. The subclinical/clinical disease ratio (excluding index cases) was 4.0. The high attack rate (37.8%) in 77 sibling contacts at risk may indictae that susceptibility to nephritis after streptococcal infection is a familial trait.

Characterization of the glomerular antibody in acute poststreptococcal glomerulonephritis

Glomerular-fixed antibody was eluted from the kidney of a 17-year-old patient who died 2 weeks after the onset of acute poststreptococcal glomerulonephritis. Elevated titers of antibodies to streptococcal enzymes were found in the serum but not in the glomerular eluate. Streptococcal M protein and anti-M protein reactivity were not detected in the eluate. Immunoglobulin G was the only serum protein demonstrated in the eluate, and it was found to have anti-IgG activity highly concentrated with respect to the serum. These studies appear to indicate that anti-IgG is involved in the immune pathogenesis of acute poststreptococcal glomerulonephritis. Native IgG may be rendered autoimmunogenic by the streptococcus with subsequent antibody production to the neoautoimmunogen. Alernatively, anti-IgG may be produced to the IgG incorporated in an exogenous streptococcal antigen-antibody complex.

Circulating immune complexes and serum immunoglobulins in acute poststreptococcal glomerulonephritis

Acute poststreptococcal glomerulonephritis (APSGN) is a disease thought to be induced by the renal deposition of circulating immune complexes. In order to test this possibility, serum samples from 119 patients with APSGN were studied for Clq binding activity (ClqBA), levels of IgG, IgM, IgA, C3 and antibody titers to streptococcal enzymes. These parameters were analyzed in relation to the clinical and laboratory data of the acute nephritic syndrome and with respect to the time elapsed from streptococcal infection and from the onset of nephritis. Elevated ClqBA was found in 66.7% of the patients in the first week of the disease and this frequency decreased progressively to 17.6% after the second week. Normal ClqBA was found in patients after the third week of nephritis. Serum levels of IgG and IgM were elevated in over 95% of the patients. Levels of IgG in excess of 2400 mg/dl were detected in 71.1% of the cases. No correlation could be found between the ClqBA and the clinical or immunoserological findings of the disease. The data support the hypothesis that circulating immune complexes are responsible for the nephritis that follows streptococcal infection.

Acute poststreptococcal glomerulonephritis in Maracaibo. II: Studies on the incidence, nature, and significance of circulating anti-immunoglobulins

Antiglobulins were measured in the sera of 82 patients with acute poststreptococcal glomerulonephritis and correlated with C1q binding activity, serum levels of immunoglobulins and C3, site of infection, antibody titres to streptococcal enzymes, and the duration of the nephritis and interval from infection. Raised serum antiglobulins were found in 89.2% of the patients. In addition, raised titres were detected at any time during the course of the disease and very early after streptococcal infection. The finding of antiglobulins soon after the infection suggests the possibility that they appear as a primary event in the disease.

Eradication of cholesteatoma

Cholesteatoma is, among the lesions appearing in chronic otitis media, the one creating most problems. We have selected 8 clinical situations, the most significant in our practice. After a short description of each, we expose our attitudes, past and present, in regard to each. Whether to use open or close techniques seems to be today's dilemma.

Evidence of an autologous immune complex pathogenic mechanism in acute poststreptococcal glomerulonephritis

Clinical and experimental studies have suggested a role for antiimmunoglobulins in the pathogenesis of glomerulonephritis associated with streptococcal infection. We attempted to localize anti-IgG in the kidneys of 22 patients who had renal biopsies performed 7 to 66 days after the onset of acute poststreptococcal glomerulonephritis (APSGN). In addition to routine localization of immunoglobulins and C3, specimens were stained with neuraminidase-treated, heat-aggregated, and unmodified IgG. Twelve biopsies showed staining with fluorescein-labeled human neuraminidase-treated IgG. A lesser number gave positive staining with the other IgG preparations. Following treatment of slides with 0.01 M citrate buffer, seven previously negative biopsies showed positive staining with neuraminidase-treated IgG. The demonstration of anti-IgG by these methods was possible in 19 out of 22 biopsies. It correlated best with the presence of C3 and IgG, and to a lesser extent with IgM, in the renal glomerulus. These results and our previous finding of elevated levels of serum anti-IgG early in the course of APSGN, and as early as 8 days following the antecedent streptococcal infection, support a role for anti-IgG in the immune pathogenesis of APSGN. Although our series of studies support the hypothesis that anti-IgG is formed to an IgG modified enzymatically by streptococcal product, the formation of this autoantibody to IgG incorporated in an exogenous (streptococcal antigen-antibody) complex can not be ruled out.

Immunopathology of the skin in acute poststreptococcal glomerulonephritis

The immunohistologic features of the skin were studied in 26 cases of poststreptococcal glomerulonephritis. Twenty-two patients had vascular and extravascular dermal deposition of IgG. Positive stains for C3 (eight patients). IgM (two patients), and fibrinogen (five patients) were confined to vessel walls. Staining with anti-IgA serum was uniformly negative. Circulating antiskin antibodies could not be detected. Extravascular accumulation of IgG has a widespread distribution in the dermal papillary layer that is highly characteristic. It was absent in 7 patients with chronic glomerulonephritis and in 11 patients with various other renal diseases. The described findings appear to occur consistently in acute poststreptococcal glomerulonephritis. The distinctive extravascular demonstration of IgG may prove to be valuable in the diagnosis of this entity.

Effects of triiodothyronine on the anemia of chronic renal failure

The present study was done in order to determine whether treatment with triiodothyronine (T3) would improve the anemia of chronic renal insufficiency. Four patients with stable renal failure and anemia were treated with 75 microgram/day of T3 for a period of four weeks. The patients were not in chronic dialysis, had normochromic normocytic anemia and hypocellular bone marrow, and showed no evidence of external blood loss during the study. They had received no iron, folic acid, or androgenic steroids for at least six months prior to the study. The administered dose of T3 was adequate to depress the serum levels of thyroid-stimulating hormone (TSH); however, there was no detectable improvement in the levels of hemoglobin, hematocrit, bone marrow cellularity, serum and erythrocyte folate determinations, serum iron (Fe), 59Fe half-life, plasma iron turnover rate, percentage Fe incorporated into red blood cells, or in the ratio of surface radioactive counting over bone marrow/liver and spleen. It is concluded that the experimental observations concerning direct bone marrow stimulation by T3 in anephric rats are probably not clinically applicable for the treatment of the anemia associated with uremia.

Immunohistologic findings in the lung in systemic lupus erythematosus

A 29-year-old woman with systemic lupus erythematosus (SLE) developed dyspnea, hemoptysis, pleuropericarditis, and azotemia shortly after an episode of arthritis and progressive hair loss. She had a high titer of radioimmune anti-DNA Antibodies, positive fluorescent anti-smooth muscle antibodies, and depressed C3 levels in her serum. Antiglomerular basement membrane antibodies were negative, and the titer of antibodies against extractable nuclear antigen was within normal limits. Cryoglobulins and lupus erythematosus cell preparations were negative. Despite steroid therapy and other supportive measures, including dialysis, she died ten days after admission. Percutaneous renal and pulmonary biopsies were performed postmortem at bedside and were processed for immunohistology. Identical granular deposits of C3 and IgG were found in both the lungs and the kidneys. This finding suggests that a common pathogenetic mechanism is operating in the development of pneumonitis and nephritis in SLE, and is in agreement with the currently held views on immune-complex diseases.

Epidemic glomerulonephritis in Maracaibo. Evidence for progression to chronicity

In 1968 an outbreak of 348 cases of acute poststreptococcal glomerulonephritis (AGN) was observed in Maracaibo, Venezuela. During the year, the epidemic had three peaks of incidence. Districts with better sanitation showed a lower incidence of disease than those with less adequate facilities. Endemic cases occur every year. Lowering of serum complement activity was observed in 96% and hypertension in 90% of the patients. The mortality rate in the acute phase during the epidemic was 1.31%. A history of antecedent infection was found in 39% of the cases. 70% of these infections were in the upper respiratory tract. During 1973-74, 120 of the patients (19 adults and 101 children) were reexamined. All but one had been completely asymptomatic. Sixteen patients (13.3%) had one or more of the following abnormalities (group A): low CCr, microscopic hematuria, proteinuria of 1 g/day or more and hypertension. One hundred and four patients (86.7%) were normal by all clinical and laboratory parameters tested (group B). The incidence of persisting disease, as judged by biochemical findings, was significantly higher (P less than .01) in adults (36.7%) than in children (8.9%). Percutaneous renal biopsies from 7 patients of group A, and 8 patients from group B, were studied by light microscopy and immune histology. All biopsies from group A patients had evidence of advanced glomerular disease by light microscopy and by immune histology. Seven biopsies from group B patients were also abnormal showing mild changes with corresponding immunologic findings. Only in one patient was the biopsy completely normal. Our studies indicate that significant numbers of patients progress towards chronicity after epidemic, poststreptococcal AGN. Such progression is more common in adults than in children.