Systemic candidiasis in a cheetah (Acinonyx jubatus)

Systemic candidiasis, with involvement of the spleen, liver, kidneys, and lymph nodes, was diagnosed in a geriatric captive cheetah (Acinonyx jubatus). The animal had a long clinical history of intermittent chronic gastritis associated with Helicobacter acinonyx and chronic renal failure, both of which were repeatedly treated with broad-spectrum antimicrobial therapy. Following euthanasia, a postmortem examination showed numerous microabscesses and granulomas composed of degenerate eosinophils and containing asteroids or Splendore-Hoeppli material throughout the body. Yeast, pseudohyphae, and infrequently branching septate hyphae, demonstrated with special stains, were identified as a Candida sp. by fluorescent antibody testing. Low genetic variation in cheetahs may increase their susceptibility to infectious agents. Additional factors contributing to the overgrowth and dissemination of Candida sp. in this case may have included changes in the bacterial flora of the alimentary tract as a result of repeated antimicrobial therapy and alterations in the topography of the alimentary mucosa caused by chronic gastritis.

Misleading manifestations of Coccidioides immitis in vivo

We describe a case of coccidioidomycosis in which several unusual morphologic forms of Coccidioides immitis occurred in biopsy tissue from the right lower lung of a patient. To our knowledge, this is the first case where so many diverse morphologic forms were manifested in a single patient in the absence of typical endosporulating spherules. Immature spherules demonstrating segmentation mimicked morula forms of Prototheca spp. Certain elements resembled budding cells of Blastomyces dermatitidis. These consisted of juxtaposed immature spherules without endospores, a germinating endospore, or thick-walled hyphal cells. Branched, septate hyphae and moniliform hyphae consisting of chains of thick-walled arthroconidia or immature spherules were also present. Complement fixation and immunodiffusion tests performed on the patient's serum were negative for C. immitis, B. dermatitidis, and Histoplasma capsulatum antibodies. Fluorescent-antibody studies were carried out with a specific C. immitis conjugate. All of the diverse fungal tissue elements stained positive with a moderate to strong (2 to 3+) intensity.

Trendelenburg positioning and continuous lateral rotation improve oxygenation in hepatopulmonary syndrome after liver transplantation

Hepatopulmonary syndrome (HPS) is characterized by hypoxia, orthodeoxia, and platypnea, associated with severe chronic liver disease. Liver transplantation is generally viewed as the only curative treatment for this syndrome, but it may be complicated by prolonged hypoxia after the procedure. We report on a 58-year-old female patient with alcoholic cirrhosis and HPS who underwent liver transplantation. She developed severe hypoxia after transplantation that improved with the initiation of Trendelenburg's positioning in combination with continuous lateral rotation. Although many techniques for dealing with posttransplant hypoxia for HPS have been described, positioning is a simple maneuver that may correct the pathophysiologic abnormalities seen in HPS by gravitationally shifting blood away from the lung bases to improve oxygenation. Although this represents a single patient, the results were reproducible, and the intervention is simple and associated with minimal potential complications. The authors think this is a useful intervention to apply to the severely hypoxic patient with HPS, and a trial with more patients is warranted.

Outcome after 'curative' surgery for carcinoma of the lower third of the rectum

BACKGROUND

Controversy exists about the optimal surgical resection for lower third rectal carcinoma. The aim of this retrospective study was to analyse whether the type of surgery is a significant predictor of outcome after curative surgery alone.

METHODS

Eighty-two consecutive patients underwent abdominoperineal rectum excision (APRE, 41 patients) or sphincter-saving operation (SSO, 41 patients) for adenocarcinoma at 3.5-7.5 cm from the anal margin. Cox proportional hazards technique with univariate and corrected (multivariate) analyses and the Kaplan-Meier life-table method were used to evaluate the data.

RESULTS

Tumour wall penetration and lymph node involvement, but not the tumour level or the type of surgery, were found to be significant predictors of outcome. The local recurrence rate at 1, 2 and 5 years was 10, 22 and 26 per cent respectively after APRE, and 5, 13 and 21 per cent after SSO. The disease-free survival rate at 1, 2 and 5 years was 85, 67 and 58 per cent respectively after APRE, and 88, 78 and 62 per cent after SSO.

CONCLUSION

Tumour-related factors are significant predictors of outcome. The type of surgery (APRE or SSO) did not seem to be a significant variable in this non-randomized study.

Monitoring of C-reactive protein after allogeneic bone marrow transplantation identifies patients at risk of severe transplant-related complications and mortality

Patterns of C-reactive protein (CRP) release were derived from frequent CRP measurements in a cohort of 66 consecutive patients receiving allogeneic bone marrow transplants (BMT) in our unit. Based on a retrospective study of clinical events occurring within the first 40 days after BMT, patients with major transplant-related complications (MTC+ group, n = 22) could be separated from those with fever or mild complications only (MTC- group, n = 44). Treatment-related mortality in the MTC+ group was significantly higher: 32 vs 0% (P < 0.001). Major complications included veno-occlusive liver disease (VOD), severe endothelial leakage syndrome (ELS), pneumonitis and acute GVHD >II. The severity of complications was reflected by the patterns of CRP release with continuously high levels preceding the maximal signs and symptoms of MTC. Univariate analysis showed that, among other variables (sex, age, disease status at transplant, +/- TBI in the conditioning regimen, +/- use of myeloid growth factors after BMT, time to reach PN >200/mm3), three factors were significantly associated with MTC: maximal levels of CRP during the post-transplant episode (CRPmax) (296.6 +/- 91.8 vs 88.9 +/- 55.8 mg/100 ml, P < 0.001), the use of unmanipulated graft (no T depletion) (46.9 vs 12.5%, P < 0.009) and the CRP level on the day of BMT (CRPo) (42.7 +/- 55.4 vs 18.2 +/- 19.5, P = 0.045). In multivariate analysis, using a stepwise logistic regression model including the same variables, CRPmax appeared to be the strongest independent variable (P < 0.001) and a reliable (94% accuracy) parameter to assess the risk of MTC. Based on this model, CRP levels of 200 and 300 mg/100 ml are associated with a risk of 48 and 94% of developing MTC, respectively. We conclude that CRP monitoring after BMT identifies patients at risk of severe transplant-related complications and mortality.

Pulmonary cryptococcosis due to a capsule-deficient strain confused with metastatic lung cancer

A patient with hepatocellular cancer developed pulmonary cryptococcosis due to infection with a capsule-deficient Cryptococcus neoformans. Pulmonary lesions initially diagnosed as metastatic cancer by chest x-ray film and CT scan were subsequently found to be fungal granulomas by autopsy. Although morphologic studies of the fungi were insufficient to render a specific mycologic diagnosis because of the absence of encapsulated yeasts, fluorescent antibody studies confirmed the diagnosis of cryptococcosis. The use of various stains and electron microscopy for the pathological differential diagnosis of cryptococcosis caused by capsule-deficient yeasts is discussed.

Primary cutaneous Aspergillus ustus infection: second reported case

We describe the second case of primary cutaneous Aspergillus ustus infection in an immunocompromised patient. Cutaneous aspergillosis was confirmed both by culture and positive fluorescent antibody staining. Few species of Aspergillus are pathogenic in human beings, and fewer still cause primary cutaneous disease. The only other reported case of aspergillosis from Aspergillus ustus occurred in an immunosuppressed patient who was temporally and geographically separated from ours.

Oral iloprost treatment in patients with Raynaud's phenomenon secondary to systemic sclerosis: a multicenter, placebo-controlled, double-blind study

OBJECTIVE

To evaluate the efficacy and tolerability of an oral preparation of iloprost, a prostacyclin analog, in patients with Raynaud's phenomenon (RP) secondary to systemic sclerosis (scleroderma).

METHODS

A multicenter, randomized, parallel-group, placebo-controlled double-blind study was performed at university and community-based medical centers. Patients were randomly assigned to receive either 50 microg of iloprost orally twice daily or an identical gelatin-coated capsule containing placebo for 6 weeks. Outcome measures included average total daily duration of RP attacks, average number of RP attacks, and RP condition scored via a standardized daily diary.

RESULTS

Three hundred eight patients with scleroderma (272 women, 36 men, mean age 49 years [range 18-80]) were enrolled. One hundred fifty seven were assigned to receive iloprost and 151 to receive placebo. One hundred forty-three patients in the iloprost group (91.1%) and 144 in the placebo group (95.4%) completed the 6-week treatment phase. Fifteen of these treated patients (8 iloprost, 7 placebo) failed to complete all of the followup visits. The mean reduction in the average duration of attacks from baseline to week 5-6 was 24.32 minutes in the iloprost group and 34.34 minutes in the placebo group (P = 0.569). Likewise, the mean reduction from baseline to week 5-6 in the daily frequency of attacks was 1.02 in the iloprost group and 0.83 in the placebo group (P = 0.459). The Raynaud's condition score, a patient-completed assessment of the severity of RP attacks, was reduced by 1.32 in the iloprost group and 1.00 in the placebo group (P = 0.323). The lack of significant difference between treatment groups did not change when a variety of factors, including use of other vasodilators, duration of disease, classification of scleroderma (limited versus diffuse), or number of baseline digital ulcers were taken into account. Premature withdrawal from the study due to adverse events occurred in 10 patients (6.4%) in the iloprost group and 3 (2.0%) in the placebo group (P = 0.058).

CONCLUSION

Oral iloprost at a dosage of 50 microg twice daily is no better than placebo for management of RP secondary to scleroderma, either during 6 weeks of treatment or during 6 weeks of posttreatment followup.

Prenatal diagnosis of the fetal Rhc genotype from peripheral maternal blood

OBJECTIVE

To determine the fetal Rhc genotype by using the polymerase chain reaction (PCR) amplification procedure and maternal blood at the different steps of the fetal cell enrichment process.

METHODS

Maternal peripheral venous blood samples were obtained from 11 pregnant women homozygous for the C antigen before amniocentesis. Three were not alloimmunized and eight were alloimmunized. The fathers were known to be heterozygous or homozygous for the c antigen by serologic testing. The mononuclear cell layer was isolated from maternal blood and flow sorted using monoclonal antibodies to CD36 or CD71 and glycophorin A. This was followed by PCR of the blood, mononuclear cells, and the sorted cells with allele-specific primers to RhCc genes. Gel electrophoresis was performed to predict fetal Rhc genotype. The fetal RhCc genotype was confirmed by serologic and DNA testing.

RESULTS

All infants were positive for the Rhc gene. The positive fetal Rhc genotype was determined correctly in three of the 11 maternal blood samples without enrichment, in six of the nine mononuclear cell samples, and in seven of the eight sorted cell samples. The fetal genotype from one sorted sample was predicted to be homozygous C. One infant was determined by serology on cord blood to be negative for the c antigen, but repeated infant DNA amplification was consistent with the c genotype.

CONCLUSION

Noninvasive fetal Rhc genotyping can be determined by PCR amplification of the rare fetal cells in maternal blood. These data reaffirm that enrichment of maternal blood for fetal cells is necessary to improve the sensitivity of the test.

Antigenic relationships among pathogenic Beauveria bassiana with Engyodontium album (= B. alba) and non-pathogenic species of the genus Beauveria

Exoantigenic extracts of 15 isolates belonging to hyalohyphomycosis-causing Beauveria bassiana (1), and Engyodontium album (1), as well as other species of the genus Beauveria (one isolate each of B. brogniartii, B. densa, B. stephanoderis, B. velata, B. vermiconia and six isolates of unknown Beauveria species) were studied. Aqueous-merthiolated extracts derived from 10-day-old Sabouraud's dextrose agar slant cultures (25 degrees C) were concentrated (25X), and reacted against rabbit anti-B. bassiana serum in the presence of partially purified homologous antigen (20X) prepared from 5-week-old shaken cultures (30 degrees C), using a microimmunodiffusion procedure. Beauveria bassiana reference antigen and antiserum reacted to produce four bands of identity. With the exception of E. album, which was negative, extracts of the isolates of B. brogniartii, B. densa, B. stephanoderis, B. velata, B. vermiconia and the unknown Beauveria species all produced 2-4 lines of identity against the homologous anti-B. bassiana serum. These results suggested that all the species of the genus Beauveria tested were antigenically related to B. bassiana. Engyodontium album demonstrated antigenic distinctness, however, from B. bassiana and thus supported the validity of this taxon.

Prevalence of sinusitis signs on MRI in a non-ENT paediatric population

In a population of 100 children with suspected intracranial neurological disease, the overall prevalence of sinusitis signs on magnetic resonance images (MRI) is 45%. This figure exceeds the adult prevalence of 39%, while the nature of the lesions is more severe in children. Furthermore, paediatric sinuses seem to be affected according to a different pattern: adults have mainly maxillary and anterior ethmoidal lesions, whereas in children the sphenoidal and posterior ethmoidal sinuses are frequently involved too. Among children, the overall prevalence increases in the presence of a history of nasal obstruction (prevalence: 50%) and recent upper respiratory tract infection (prevalence: 81%) as well as when bilateral mucosal swelling (prevalence: 80%) or purulent secretions (prevalence: 100%) are seen on anterior rhinoscopy.

Serodiagnosis of human and animal pythiosis using an enzyme-linked immunosorbent assay

Conventional serodiagnosis of Pythium insidiosum infections involves the use of the immunodiffusion (ID) test. This test specifically diagnoses human and animal pythiosis. The test, however, has limited sensitivity and does not detect some culturally proven cases of the disease. Because of the increased recognition of pythiosis among humans and animals, we developed and evaluated an enzyme-linked immunosorbent assay (ELISA) using a soluble antigen from broken hyphae of P. insidiosum. Studies were carried out with sera from five humans and eight animals with culturally and/or histologically proven pythiosis. Some of these sera were negative in the ID test for pythiosis. Heterologous case sera from thirteen humans and two horses, plus 5 sera from healthy humans and 17 from healthy animals, were tested. Of the pythiosis case sera tested, the ID test detected only 8 of 13 (61.5%), whereas the ELISA detected all of them (100%). The ID and ELISA tests were entirely specific and gave negative results or low titers respectively, with sera from humans and animals with heterologous fungal infections or with no apparent illness. No correlation was found between the height of the ELISA titers and negative or positive sera in the ID test. Our results indicate that the ELISA is a reliable serodiagnostic test for pythiosis. It is as specific as the ID test but more sensitive.

Associations of GAD65- and IA-2- autoantibodies with genetic risk markers in new-onset IDDM patients and their siblings. The Belgian Diabetes Registry

OBJECTIVE

To investigate the association of GAD (65-kDa) autoantibodies (GAD65-Abs) and IA-2 autoantibodies (IA-2-Abs) with human leukocyte antigen (HLA)-DQ and insulin gene (INS) risk markers in patients with recent-onset IDDM and their siblings.

RESEARCH DESIGN AND METHODS

Blood was sampled from 608 recent-onset IDDM patients and 480 siblings, aged 0-39 years and consecutively recruited by the Belgian Diabetes Registry, to determine GAD65- and IA-2-Ab (radiobinding assay), HLA-DQ- (allele-specific oligonucleotyping), and INS-genotypes (restriction fragment length polymorphism analysis; siblings, n = 439).

RESULTS

At the onset of IDDM, GAD65-Abs were preferentially associated with two populations at genetic risk but only in the 20- to 39-year age-group: 1) their prevalence was higher in carriers of DQA1*0301-DQB1*0302 (88 vs. 73% in non[DQA1*0301-DQB1*0302], P = 0.001), and 2) an association was found in patients lacking this haplotype but carrying DQA1*0501-DQB1*0201, together with INS I/I (87 vs. 54% vs. non[INS I/I], P = 0.003). Siblings of IDDM patients also presented the association of GAD65-Abs with DQA1*0301-DQB1*0302 (13 vs. 2% non[DQA1*0301-DQB1*0302], P < 0.001), while associations with the second genetic risk group could not yet be assessed. At the onset of IDDM, IA-2-Ab prevalence was higher in carriers of DQA1*0301-DQB1*0302 (69 vs. 39% non[DQA1*0301-DQB1*0302], P < 0.001) but not of DQA1*0501-DQB1*0201 or INS I/I. This association was present in both the 0- to 19- and the 20- to 39-year age-groups. It was also found in siblings of IDDM patients (4 vs. 0% non[DQA1*0301-DQB1*0302], P < 0.001).

CONCLUSIONS

Both GAD65- and IA-2-Abs exhibit higher prevalences in presence of HLA-DQ- and/or INS-genetic risk markers. Their respective associations differ with age at clinical onset, suggesting a possible usefulness in the identification of subgroups in this heterogeneous disease.

Effects of antihistamines in adult asthma: a meta-analysis of clinical trials

A meta-analysis of clinical trials of antihistamines was performed to assess the risk-benefit ratio of this therapeutic class in asthma. Double-blind randomized placebo-controlled trials assessing lung function changes under repeated use of antihistamine in adult asthma were selected, and the quality of studies was scored. Morning peak expiratory flow rate (PEFR) was the primary outcome: an effect size was computed for each study, with a 95% confidence interval (95% CI), and a mean effect size was computed, combining all studies. Effect sizes were also determined for secondary outcomes: evening PEFR, forced expiratory volume in one second (FEV1) and daily use of inhaled beta-agonists. Nineteen studies were included in the meta-analysis. Mean quality score of studies was 59.4%; asthma was generally uncontrolled at study inclusion. Altogether, 582 antihistamine-treated and 557 placebo-treated asthma patients were evaluable. Antihistamines had little effect on airway calibre (mean increase in morning PEFR: 13 L x min(-1); 95 CI: 8-18 L x min(-1)) and on use of inhaled beta-agonists (mean reduction in daily use: 0.4 doses; 95% CI: 0-0.8 doses). Sedation occurred more often with antihistamines than with placebo (p<0.001); additional side-effects were mentioned, including weight gain, altered taste, headache and dry mouth. Respiratory and systemic effects observed after repeated use of antihistamines do not support the use of these medications in the treatment of asthma; better designed studies could affect this appraisal.

PSA evolution: a prognostic factor during treatment of advanced prostatic carcinoma with total androgen blockade. Data from a Belgian multicentric study of 546 patients

OBJECTIVES

To study the prognostic value of the prostate-specific antigen (PSA) response and its relationship with other initial prognostic factors during the treatment of advanced prostatic carcinoma with total androgen blockade.

METHODS

Five hundred forty-six patients with advanced loco-regional (M0) or distant metastatic (M1) prostatic carcinoma treated with flutamide combined with either orchiectomy or LHRH analogues were included in this analysis. Initial patients characteristics and the PSA response were evaluated in relation to progression-free survival using a univariate and multivariate (Cox regression) analysis.

RESULTS

The following prognostic factors were indicative of a decrease in progression-free survival: the absence of PSA normalization (< 4 ng/ml) after 3 or 6 months, M1 stage, high G grade, ECOG performance status > 1, presence of pain and absence of dysuria. In M1 patients the combination of PSA normalization after 3 or 6 months with initial G grade and ECOG performance status had the strongest predictive value.

CONCLUSIONS

This study demonstrates that PSA normalization after 3 or 6 months along with initial tumor stage, grade and health status of the patient are the most important prognostic factors related to progression-free survival in the hormonal treatment of advanced prostatic carcinoma.

Immunohistologic identification of Aspergillus spp. and other hyaline fungi by using polyclonal fluorescent antibodies

Isolation and identification of pathogenic Aspergillus and Fusarium spp. from clinical materials provide the most accurate means for establishing a diagnosis of infections by these molds. Such efforts, however, are not always successful. Histologic diagnosis also has its limitations. In vivo the hyphae of Aspergillus and Fusarium spp. are very similar and their in situ manifestations are not pathognomonic. To improve the histologic diagnosis of infections by Aspergillus and Fusarium species, we developed polyclonal fluorescent-antibody reagents to Aspergillus fumigatus and Fusarium solani and evaluated their diagnostic utilities. Our studies revealed that A. fumigatus and F. solani share epitopes not only with one another but also with other Aspergillus and Fusarium spp. as well as with Paecilomyces lilacinus and Pseudallescheria boydii. Adsorption of the A. fumigatus conjugate with cells of Fusarium proliferatum and F. solani and F. solani antiserum with cells of Aspergillus flavus resulted in reagents that distinguished Aspergillus spp. from Fusarium spp. but that still cross-stained P. lilacinus and P. boydii. Adjunctive use of a specific P. boydii conjugate enabled the identification of Aspergillus spp., Fusarium spp., P. lilacinus, and P. boydii in formalin-fixed tissue sections from 19 humans with culture-proven cases of mycotic infection.

Outbreak of sporotrichosis among tree nursery workers

In spring 1994, an outbreak of sporotrichosis occurred at a tree nursery in Florida; 9 (14%) of 65 workers involved in production of sphagnum moss topiaries developed lymphocutaneous sporotrichosis. A cohort study of all 65 employees was conducted to identify risk factors for sporotrichosis, and an environmental investigation was done. The risk of sporotrichosis increased significantly with the duration of working with sphagnum moss (P < .05), in particular with filling topiaries (P < .05), and with having less gardening experience (P < .05). Wearing gloves was protective (P < .005). Sporothrix schenckii was cultured from patients and sphagnum moss used in topiary production. Use of restriction fragment length polymorphism revealed an identical pattern for patient isolates that was different from the patterns of environmental isolates. Physicians should be aware of sporotrichosis in patients with ulcerative skin lesions who have a history of occupational or recreational exposure to sphagnum moss.

A Rorschach comparison of psychopathic and nonpsychopathic conduct disordered adolescents

Forty-eight male subjects who met the DSM-IV (APA, 1994) criteria for conduct disorder (CD) were assessed for psychopathy level using a modified version of the Psychopathy Checklist-Revised (PCL-R, Forth, Hart, & Hare, 1990). Rorschach variables associated with self-perception, affects, and object relations, early behavioral problems and history of violence were compared between psychopathic and nonpsychopathic CD adolescents. Psychopathic CD subjects were significantly more self-centered and violent than nonpsychopathic CD subjects. Decreased attachment and anxiety were found in both CD groups. Our study adds empirical support to the heterogeneity noted among CD adolescents (PCL-R), supports the utility of the Rorschach for detecting individual differences among CD subjects, and extends the empirical work of Gacono and Meloy (1994) to adolescent psychopathy.

Study of human occipital alpha rhythm: the alphon hypothesis and alpha suppression

Alpha rhythm of the parieto-occipital area is comprised of a parade of short-lived cortical excitations (alphons), each of which exhibits oscillations having a stable period within the alpha bandwidth. Strong alpha rhythm is produced by alphons extending over a larger cortical area, although an enhanced cortical current density may also contribute. Local suppression of alpha rhythm indicates when specific cortical areas become engaged in sensory or cognitive functions. Examples are provided for mental imagery, visual memory, auditory memory, and silent rhythming.

Generalized anxiety disorder in chronic fatigue syndrome

A structured psychiatric interview, forming part of a global psychopathological approach, revealed higher prevalence rates of current and lifetime psychiatric disorders and a higher degree of psychiatric comorbidity in patients with chronic fatigue syndrome (CFS) than in a medical control group. In contrast to previous studies, a very high prevalence of generalized anxiety disorder (GAD) was found in CFS, characterized by an early onset and a high rate of psychiatric comorbidity. It is postulated that GAD represents a susceptibility factor for the development of CFS. A significantly higher prevalence was also observed for the somatization disorder (SD) in the CFS group. Apart from a higher female-to-male ratio in fibromyalgia, no marked differences were observed in sociodemographic or illness-related features, or in psychiatric morbidity, between CFS patients with and without fibromyalgia. CFS patients with SD have a longer illness duration and a higher rate of psychiatric comorbidity. These findings are consistent with the suggestion of Hickie et al. (1) that chronic fatigued subjects with SD should be distinguished from subjects with CFS.

Physical fatigability and exercise capacity in chronic fatigue syndrome: association with disability, somatization and psychopathology

Physical fatigability and avoidance of physically demanding tasks in chronic fatigue syndrome (CFS) were assessed by the achievement or nonachievement of 85% of age-predicted maximal heart rate (target heart rate, THR) during incremental exercise. The association with functional status impairment, somatization, and psychopathology was examined. A statistically significant association was demonstrated between this physical fatigability variable and impairment, and a trend was found for an association with somatization. No association was demonstrated with psychopathology. These results are in accordance with the cognitive-behavioral model of CFS, suggesting a major contribution of avoidance behavior to functional status impairment; however, neither anxiety nor depression seem to be involved in the avoidance behavior. Aerobic work capacity was compared between CFS and healthy controls achieving THR. Physical deconditioning with early involvement of anaerobic metabolism was demonstrated in this CFS subgroup. Half of the CFS patients who did not achieve THR did not reach the anaerobic threshold. This finding argues against an association in CFS between avoidance of physically demanding tasks and early anaerobic metabolism during effort.