Are pre-operative vocal fold checks necessary?

Over a 26-year period, from 1970 to 1995, 2250 pre-operative vocal fold checks were carried out by the ENT team at Manchester Royal Infirmary in patients undergoing thyroid, parathyroid and cardiothoracic surgery. A register was kept of all pre-operative fold checks. This register was retrospectively analysed and 23 vocal fold palsies were documented. In six of these patients the notes were either missing or incomplete. All of the remaining 17 patients had a history suggestive of vocal fold palsy. We suggest that in the absence of symptoms, either current or on history, a routine pre-operative vocal fold check is unnecessary.

Systemic absorption of gentamicin ear drops

Aminoglycoside-containing topical preparations are commonly used in the treatment of chronic suppurative otitis media and otitis externa. We report a case where systemic absorption of topical Gentisone HC occurred producing a serum gentamicin level of 6.2 micrograms/ml.

Multiple cutaneous metastases from laryngeal carcinoma

A case of laryngeal squamous cell carcinoma recurrence presenting as multiple cutaneous metastases is presented. Such metastases are rare and are associated with a poor prognosis. Treatment is usually aimed at providing pain relief in these patients with a limited life expectancy.

Tonsillar metastasis from a renal cell carcinoma presenting as a quinsy

We present a rare case of renal cell carcinoma metastatic to the tonsil. Tonsillectomy was inadvertently performed during an attempt to drain what was clinically a peritonsillar abscess.

An unusual complication of T-tubes

The morbidity of long-term ventilation tubes (Goode T-tubes) is often discussed with reference to otorrhoea, tympanosclerosis and long-term perforation. We report three cases of the T-tube slipping into the middle-ear cleft. In two of the three patients this was asymptomatic and the T-tubes were left in situ. In the third patient this complication was documented on three occasions when the T-tube was removed and reinserted for recurrent effusions. We are unaware of this complication being previously reported in the literature.

Analyses of HLA-DQ alleles in recurrent spontaneous abortion (RSA) couples

PROBLEM

The influence of HLA sharing on pregnancy outcome is controversial. In renal transplantation, HLA-DQB1 donor-recipient mismatches have been shown beneficial for long-term transplant success. Since pregnancy is defined as Nature's allograft, we investigated the relevance of HLA-DQ mismatching in normal reproducing couples compared to couples experiencing RSA.

METHOD

Unexplained RSA couples referred to our laboratory for immunological testing were classified by immunological findings and obstetrical history. Primary RSA couples shared > or = 2 HLA-A, B, or DR antigens, had no cytotoxic anti-paternal antibodies, and no gestation beyond 20 weeks. Secondary RSA couples had cytotoxic anti-paternal antibodies and RSA after a live birth. HLA-DQA1 and DQB1 alleles were identified by PCR-SSP.

RESULTS

No differences in DQA1 and DQB1 mismatch were observed among RSA patients and controls. DQA1-DQB1 haplotype mismatches were not different among the three groups of couples.

CONCLUSIONS

In contrast to renal transplant, HLA-DQ incompatibility did not differ among RSA couples compared with successful reproducing couples.

An experimental vaccine cocktail for Plasmodium falciparum malaria

Surface proteins from several different life-cycle stages of the malaria parasite Plasmodium falciparum were expressed at high levels in the yeast Saccharomyces cerevisiae. Purified proteins, both individually and in cocktails, were used to immunize mice and goats in conjunction with either Freund's adjuvant or a muramyl tripeptide-based adjuvant. Immune responses were measured by enzyme-linked immunosorbent assays and by the ability of antisera to inhibit (1) the invasion of hepatocytes by live sporozoites, (2) in vitro invasion of human erythrocytes by live merozoites, and (3) the development of oocytes in the mosquito vector. These results suggest that cocktails of different stage-specific antigens can provide the components necessary to block the development of the malaria parasite at multiple stages of its life cycle.

Recombinant Pfs25 protein of Plasmodium falciparum elicits malaria transmission-blocking immunity in experimental animals

Pfs25 is a sexual stage antigen of Plasmodium falciparum that is expressed on the surface of zygote and ookinete forms of the parasite. Monoclonal antibodies directed against native Pfs25 can block completely the development of P. falciparum oocysts in the midgut of the mosquito vector. Thus, this 25-kD protein is a potential vaccine candidate for eliciting transmission-blocking immunity in inhabitants of malaria endemic regions. We have synthesized, by secretion from yeast, a polypeptide analogue of Pfs25 that reacts with conformation-dependent monoclonal antibodies, and elicits transmission-blocking antibodies when used to immunize mice and monkeys in conjunction with a muramyl tripeptide adjuvant. Our results suggest the further evaluation of recombinant DNA-derived Pfs25 in transmission-blocking vaccination studies in humans.

Protective immunity induced in Aotus monkeys by recombinant SERA proteins of Plasmodium falciparum

We describe the vaccination of Panamanian monkeys (Aotus sp.) with two recombinant blood stage antigens that each contain a portion of the N-terminal region of the SERA (serine repeat antigen) protein of the malaria parasite Plasmodium falciparum. We immunized with either a 262-amino-acid SERA fragment (SERA I) that contains amino acids 24 to 285 of the 989-amino-acid protein or a 483-amino-acid SERA fragment (SERA N) that contains amino acids 24 to 506 as part of a fusion protein with human gamma interferon. The recombinant proteins were shown to stimulate protective immunity when administered with complete and incomplete Freund adjuvant. Four of six immunized monkeys challenged by intravenous inoculation with blood stage P. falciparum developed parasitemias that were reduced by at least 1,000-fold. Two of six immunized monkeys developed parasitemias which were comparable to the lowest parasitemia in one of four controls and were 50- to 1,000-fold lower than in the other three controls.

Immunogenicity of recombinant Plasmodium falciparum SERA proteins in rodents

We have expressed defined regions of the serine-repeat antigen (SERA) of the Honduras-1 strain of Plasmodium falciparum in the yeast Saccharomyces cerevisiae. Amino-terminal domains of the natural SERA protein have been shown previously to be targets for parasite-inhibitory murine monoclonal antibodies. Two recombinant SERA antigens were selected for purification and immunological analysis. The first (SERA 1), corresponding to amino acids 24-285 of the natural SERA precursor, was expressed by the ubiquitin fusion method. This allowed for in vivo cleavage by endogenous yeast ubiquitin hydrolase, and subsequent isolation of the mature polypeptide. The second, larger protein (SERA N), encompassing amino acids 24-506, was expressed at only low levels using this system, but could be isolated in high yields when fused to human gamma-interferon (gamma-IFN). Each purified protein was used to immunize mice with either Freund's adjuvant or a muramyl tripeptide adjuvant that has been used in humans. Sera from immunized mice were shown to be capable of in vitro inhibition of invasion of erythrocytes by the Honduras-1 strain of P. falciparum. The results suggest that a recombinant SERA antigen may be an effective component of a candidate malaria vaccine.

Role of organ-associated NK cells in decreased formation of experimental metastases in lung and liver

Mice treated with anti-asialo GM1 (asGM1) serum exhibited increased formation of experimental metastases in lung and liver after i.v. challenge with B16 melanoma or Lewis lung carcinoma. This increased metastasis formation coincided with decreased splenic NK activity and increased survival of i.v. injected radiolabeled tumor cells. In contrast, the injection of mice with the pyran copolymer maleic anhydride divinyl ether (MVE-2) augmented NK activity in the spleen and significantly depressed the formation of experimental metastases in the lungs and liver. However, a single or double administration of anti-asGM1 antiserum to MVE-2-pretreated mice failed to inhibit the immunoprophylaxis associated with MVE-2 administration, although it did decrease splenic NK activity and also increased the survival of i.v.-injected radiolabeled tumor cells. To address the mechanism for this dichotomy, we examined NK activity not only in the spleen but also in the blood, lungs, and livers of MVE-2-treated mice. Levels of NK activity in the lungs and liver were several-fold higher than those observed in spleen and blood. However, MVE-2-augmented NK activity in lung and liver was more resistant to depletion by the standard regimen of anti-asGM1 treatment than was NK activity in blood and spleen, and required two high-dose administrations of a higher titered antiserum for depletion of the augmented response. This high-dose regimen removed all detectable NK activity from the lung and liver, and concomitantly eliminated the metastasis-inhibiting effect of MVE-2. These data are consistent with a role for organ-associated NK cells in inhibiting metastasis formation during the extravasation and/or early postextravasation phases of the metastatic process. The results also suggest that biologic effects of NK activity in spleen and blood can be dissociated from those mediated by NK activity in other organs by use of different treatment regimens with anti-asGM1 serum. Finally, because NK activity in target organs can be augmented to an even greater extent than in the blood and spleen by at least some biologic response modifiers (BRMs), organ-associated NK activity should be considered as a possible mechanism for the therapeutic effects of BRM treatment.

Role of organ-associated NK cells in decreased formation of experimental metastases in lung and liver

Mice treated with anti-asialo GM1 (asGM1) serum exhibited increased formation of experimental metastases in lung and liver after i.v. challenge with B16 melanoma or Lewis lung carcinoma. This increased metastasis formation coincided with decreased splenic NK activity and increased survival of i.v. injected radiolabeled tumor cells. In contrast, the injection of mice with the pyran copolymer maleic anhydride divinyl ether (MVE-2) augmented NK activity in the spleen and significantly depressed the formation of experimental metastases in the lungs and liver. However, a single or double administration of anti-asGM1 antiserum to MVE-2-pretreated mice failed to inhibit the immunoprophylaxis associated with MVE-2 administration, although it did decrease splenic NK activity and also increased the survival of i.v.-injected radiolabeled tumor cells. To address the mechanism for this dichotomy, we examined NK activity not only in the spleen but also in the blood, lungs, and livers of MVE-2-treated mice. Levels of NK activity in the lungs and liver were several-fold higher than those observed in spleen and blood. However, MVE-2-augmented NK activity in lung and liver was more resistant to depletion by the standard regimen of anti-asGM1 treatment than was NK activity in blood and spleen, and required two high-dose administrations of a higher titered antiserum for depletion of the augmented response. This high-dose regimen removed all detectable NK activity from the lung and liver, and concomitantly eliminated the metastasis-inhibiting effect of MVE-2. These data are consistent with a role for organ-associated NK cells in inhibiting metastasis formation during the extravasation and/or early postextravasation phases of the metastatic process. The results also suggest that biologic effects of NK activity in spleen and blood can be dissociated from those mediated by NK activity in other organs by use of different treatment regimens with anti-asGM1 serum. Finally, because NK activity in target organs can be augmented to an even greater extent than in the blood and spleen by at least some biologic response modifiers (BRMs), organ-associated NK activity should be considered as a possible mechanism for the therapeutic effects of BRM treatment.

Secondary syphilis presenting as a palisading granuloma

A diagnosis of secondary syphilis was made in a 37-year-old man who presented with a papular eruption and a penile ulceration. Skin biopsy revealed a palisading granuloma similar to that seen in granuloma annulare. This represents a histologic finding that has not been described for early secondary syphilis.

Livedo reticularis with ulcers and circulating immune complexes

Livedo reticularis is a reticulate skin pattern that is idiopathic or associated with systemic disease. A 30-year-old white man with livedo reticularis, winter ulcerations, and a peripheral neuropathy is described. His only laboratory abnormality remains the presence of circulating immune complexes. Therapy of this patient's condition and the significance of these immune complexes are discussed.

Treatment of chromomycosis with ketoconazole and 5-fluorocytosine

Chromomycosis is a disfiguring cutaneous mycosis that is often recalcitrant to therapy. We describe a case of chromomycosis of the lower extremities that is being successfully treated with ketoconazole and 5-fluorocytosine (5-FC) after treatment with ketoconazole alone had failed. In vitro studies showed that the drugs acted synergistically against the strain of Fonsecaea pedrosoi which was isolated from the patient's lesion.