Primary cutaneous cryptococcal cellulitis secondary to insect bite in an immunosupressed patient after liver transplantation

Cutaneous cryptococcosis is usually a manifestation of disseminated disease, especially in immunosuppressed patients. Primary cutaneous cryptococcosis has also been described in some patients without evidence of systemic disease. Distinguishing between primary and secondary cutaneous cryptococcosis may be difficult as patients can be asymptomatic or cutaneous lesions may precede systemic involvement by some months. Features supporting primary disease are a history of cutaneous inoculation, and solitary superficial lesions on uncovered parts of the body. We present a liver transplant patient with cutaneous cryptococcal cellulitis subsequent to an insect bite, without systemic involvement and with excellent response to treatment with amphotericin B for 15 days and surgical debridement plus oral fluconazole for 3 months. In immunosupressed patients with cellulitis a cryptococcal infection must be excluded. If cutaneous cryptococcosis is diagnosed, systemic evaluation and prompt lengthy treatment are required.

Neuronal and inducible nitric oxide synthase expression in the rat cerebellum following portacaval anastomosis

In order to determine the role of neuronal nitric oxide synthase (nNOS) and inducible nitric oxide synthase (iNOS) in the pathogenesis of experimental hepatic encephalopathy (HE), the expression of both was analyzed in the cerebellum of rats 1 month and 6 months after performing portacaval anastomosis (PCA). In control cerebella, nNOS immunoreactivity was mainly observed in the molecular layer (ML), whereas the Purkinje cells did not express nNOS. However, nNOS expression was detected in the Purkinje cells at 1 month after PCA, correlating with a decrease in nNOS expression in the ML--part of an overall reduction in cerebellar nNOS concentrations (as determined by Western blotting). At 6 months post-PCA, a significant increase in nNOS expression was observed in the ML, as well as increased nNOS immunoreactivity in the Purkinje cells. nNOS immunoreactivity was also observed in the Bergmann glial cells of PCA-treated rats. While no immunoreactivity for iNOS was seen in the cerebella of control rats, iNOS immunoreactivity was significantly induced in the cerebellum 1 month after PCA. In addition, the expression of iNOS was greater at 6 months than at 1 month post-PCA. Immunohistochemical analysis revealed this iNOS to be localized in the Purkinje cells and Bergmann glial cells. The induction of iNOS in astroglial cells has been associated with pathological conditions. Therefore, the iNOS expression observed in the Bergmann glial cells might play a role in the pathogenesis of HE, the harmful effects of PCA being caused by them via the production of excess nitric oxide. These results show that nNOS and iNOS are produced in the Purkinje cells and Bergmann glial cells following PCA, implicating nitric oxide in the pathology of HE.

Impact of lesion size on photodynamic therapy with verteporfin of predominantly classic lesions in age related macular degeneration

AIM

To determine if photodynamic therapy (PDT) outcomes are related to lesion size in patients with subfoveal predominantly classic choroidal neovascularisation (CNV) secondary to age related macular degeneration (AMD).

METHODS

According to greatest linear dimension (GLD) of the entire lesion determined with fluorescein angiography (FA) patients were divided into two groups. In the first group GLD was <3000 microm and in the second one GLD was 3000-5000 microm. All eyes were treated with standard PDT with the verteporfin protocol. The primary outcome was the proportion of eyes in both groups that did not show significant leakage in FA at the end of follow up. Secondary outcomes were changes in GLD and in best corrected visual acuity (BCVA).

RESULTS

64 patients (mean (SD) age, 76.7 (7.7) years; range 58-95 years) were recruited to participate in the study. All participants in the study completed the follow up time (mean 16.6 months). 24 patients (75%) in the group of smaller lesions (n = 32) compared with 15 patients (46.8%) in the group of larger lesions (n = 32) did not show significant leakage in FA at the end of follow up (p = 0.02). A GLD increase >1000 microm was recorded in nine eyes (28.1%) in the group of smaller lesions and in 16 eyes (50%) in the group of larger lesions (p = 0.07). 22 eyes (68.7%) in the group of smaller lesions compared with 19 eyes (59.3%) in the group of larger lesions lost less than three lines of vision (p = 0.06). Relevant side effects related to verteporfin therapy were not recorded, except for four patients (6.2%) with infusion related back pain.

CONCLUSIONS

These results suggest that lesion size at baseline may be a prognosis factor in PDT in patients with subfoveal predominantly classic CNV secondary to AMD. There are no relevant side effects or safety concerns derived from verteporfin therapy.

Down-regulation of astroglial proteins in the rat cerebellum after portacaval anastomosis

The effect of short-term portacaval anastomosis (PCA) on the expression of specific astroglial markers [glial fibrillary acidic protein (GFAP) and glutamine synthetase (GS)] in the rat cerebellum was examined to determine the influences of PCA on astroglial cells. The results suggest that PCA directly interferes with astroglial cytoskeleton, as indicated by the irregular distribution and reduced expression of GFAP observed after 1 month. PCA also decreased GS immunoreactivity in the Bergmann glial processes of the molecular layer, as well as in astrocytes of the granule cell layer. It might also modulate glutamatergic nervous activity as GS expression was reduced in 1 month post-PCA brains. Moreover, the GFAP and GS levels in PCA-exposed rats were lower than in control rats. This might contribute to the appearance of encephalopathy by increasing extracellular glutamate and/or ammonia concentrations. These results show that short-term PCA interferes with astroglial protein expression, with both GFAP and GS levels falling in astroglial cells.

[Minimally invasive approach of Nuss for the correction of pectus excavatum]

Since December 1999 to November 2003, we treated 68 patients with pectus excavatum using the Nuss minimally invasive procedure. Their ages were between 6 and 24 years old, with a mean of 12 years. Average Haller index was 4.1. Lateral stabilisers were used in all the cases, in 28% of them, two stabilisers were used. Mean operative time was 70 minutes (range 40 to 120). A thoracic epidural catheter was used for postoperative analgesia in 87% of the cases, with a mean duration of 3 days. The most frequent early complication was residual pneumothorax, which resolved spontaneously in 24% of the cases. The average hospital stay was 5.7 days. 93% of patients had excellent, very good or good results, in 5% of the cases the results were fair, and 2% had poor results due to thoracic asimetry and/or sternal rotation. The Nuss minimally invasive procedure is a useful method for treatment of pectus excavatum's patients.

Prenatal cannabinoid exposure down- regulates glutamate transporter expressions (GLAST and EAAC1) in the rat cerebellum

Efficient reuptake of synaptically released glutamate is essential for preventing glutamate receptor overstimulation and neuronal death. Glutamate transporters play a vital role in removing extracellular glutamate from the synaptic cleft. This study analyzed the expression of the glial (GLAST) and neuronal (EAAC1) subtypes of glutamate transporter in the cerebellum of male and female offspring exposed pre- and postnatally to Delta9-tetrahydrocannabinol (THC, the main component of marijuana). Pregnant rats were administered saline or THC from gestational day 5 to postnatal day 20 (PD20). The expression of glutamate transporters was examined at PD20, PD30 and PD70 (10 and 50 days after THC withdrawal) to analyze the short- and long-term effects of prenatal THC exposure. The expression of the glutamate transporter GLAST in astroglial cells and EAAC1 in Purkinje neurons decreased in THC-exposed offspring compared to controls. This reduction was observed at all ages but mainly in males. Moreover, the glial glutamate transporter level in THC-exposed rats (quantified by Western blot) was lower than in control rats. These results suggest that THC exposure during cerebellar development may alter the glutamatergic system not only during the period of drug exposure but in the postnatal stage following withdrawal. The down-regulation reported here might reflect an abnormal maturation of the glutamatergic neuron-glia circuitry.

[Bronchial carcinoid tumor: a retrospective analysis of 62 surgically treated cases]

OBJECTIVE

To evaluate the results of surgical treatment for lung carcinoid tumor.

PATIENTS AND METHOD

The medical records of 62 patients who underwent surgical intervention for lung carcinoid tumor between May 1985 and October 2000 were reviewed.

RESULTS

Fifty-two patients had typical carcinoid tumors and 10 had atypical carcinoid tumors. Hilar or mediastinal lymph node metastases were present in 9 patients. Distant metastasis occurred in 5 patients and was significantly more frequent in those with the atypical carcinoid histological subtype. The overall survival rate at 15 years was 70%, with a mean survival rate of 138 (SD 11) months, calculated with the Kaplan-Meier method. We found no statistically significant correlation between smoking and the development of carcinoid tumors.

CONCLUSIONS

Although carcinoid tumors behave like low-grade malignant tumors, they should be treated in the same way as other malignant lung tumors. Curative surgical resection is the technique of choice whenever possible.

Characterization of allergens secreted by Anisakis simplex parasite: clinical relevance in comparison with somatic allergens

BACKGROUND

Diagnostic methods for the study of allergic reactions to Anisakis simplex (A.s.) based on whole-body extracts of the larva are clearly insufficient.

OBJECTIVES

To study the allergenicity of the proteins secreted by the parasite. Comparison with somatic antigens and determination of their clinical importance in allergic patients were also addressed.

METHODS

An excretory/secretory (E/S) extract was produced by culturing third-stage A.s. larvae. It was used to perform immediate skin tests and to determine specific IgE in 10 patients diagnosed with allergy to A.s. Both tests were compared with the results obtained with the whole-body extract (somatic (S)). The molecular weight (MW) of their allergens was determined by immunoblotting, and a single-blind placebo-controlled oral challenge with E/S proteins was performed. Finally, allergens' resistance to gastric pepsin and acid pH was explored.

RESULTS

A.s. larvae secreted allergens more potent than those present in the S extract. The skin prick test wheal area produced by E/S molecules and the absorbance obtained in the determination of specific IgE with these allergens (ELISA) were 5.8 times bigger than those obtained with S extract. MW allergens of 72 and 56 kDa in E/S extracts and those of 56, 48 and 43 kDa in S extract were recognized by more than 50% of the patients. Partial cross-reactivity between them was revealed by immunoblotting inhibition studies. Oral challenge with E/S extract (up to 479 microg) was negative in all the patients. Treatment of E/S proteins with gastric pepsin inhibited the binding of the E/S allergens for specific IgE. The acid pH did not affect the overall binding of IgE to E/S extract. It decreased by 15.23% and 19.96% at pH 4 and 2, but the difference was not statistically significant.

CONCLUSION

A.s. secretes allergens more potent than somatic antigens and should be used in the diagnostic procedures. These allergens are inactivated by the pepsin, which supports the theory that live larva is necessary to induce an allergic reaction in most of the patients.

[Video-assisted thoracoscopic sympathectomy for the treatment of facial flushing: ultrasonic scalpel versus diathermy]

OBJECTIVE

To evaluate the advantages of the ultrasonic scalpel compared to electrocoagulation in patients undergoing video-assisted thoracoscopic sympatholysis or sympathectomy for uncontrolled facial blushing.

METHODS

Two hundred bilateral video-assisted thoracoscopic procedures to interrupt transmission in the thoracic sympathetic nerve were performed in 100 patients with incapacitating facial blushing. In 2 cases, the video-assisted approach was chosen because of pleural symphysis. The mean age of patients was 34 years (range: 15 to 67). The sympathetic chain was interrupted from the lower portion of the first thoracic ganglion through the third.

RESULTS

All patients were discharged within 24 hours with the exception of one on whom an emergency thoracotomy had been performed. No complications were reported in the group in which a harmonic scalpel was used. One case of temporary Horner syndrome (4 months) and 3 cases of persistent chest pain (more than 2 weeks) were reported in the diathermy group. There were 9 cases of partial and asymptomatic pneumothorax that resolved without treatment or prolonged hospital stays.

CONCLUSION

Dissection of the sympathetic nerve is accomplished more reliably and with better visualization with the ultrasonic scalpel. Peripheral lesions in lung parenchyma and adjacent tissues (intercostal vessels and nerves) are avoided, as is Horner syndrome, which can be caused by dispersion of heat. Use of the ultrasonic scalpel would also lead to a lower incidence of postoperative neuralgia.

Expression of the mu-opioid receptor in the anterior pituitary gland is influenced by age and sex

To analyze whether opioids are able to modulate endocrine regulation by acting directly on rat pituitary cells, an immunohistochemical study of micro-opioid receptor expression in these cells was performed, with attention given to the analysis of potential age- and sex-related variations in receptor expression patterns. In both sexes, the micro-opioid receptor was detected in the pituitary pars distalis. However, significant age-related differences were observed. Both in male and female rats, the percentage of micro-opioid receptor-expressing cells decreased significantly from postnatal week one through the 24 months of our study. Interestingly, pituitary cells containing the micro-opioid receptor were significantly more numerous in male than in female, with exception of the pre-pubertal phase and old rats. According to two-way analysis of variance, the gender-related differences in micro-receptor expression were independent of age-related variations. Thus, without excluding hypothalamic actions, our results suggest that opioids may exert their endocrine function by acting directly on pituitary cells.

Involvement of 5-HT1A receptors in behavioural effects of the cannabinoid receptor agonist CP 55,940 in male rats

We have studied the possible interaction between the cannabinoid receptor agonist CP 55,940 (1 and 50 microg/kg) and the 5-HT1A receptor antagonist WAY 100635 (1 mg/kg) in the modulation of plus-maze and holeboard activity in Wistar adult male rats. In the plus-maze, the higher dose of CP 55,940 induced an anxiogenic-like effect, whereas the lower dose induced anxiolytic-like responses. The 5-HT1A antagonist, which was silent in this test, attenuated the anxiogenic, but not the anxiolytic, effect of CP 55,940. In the holeboard, the higher dose of CP 55,940 significantly decreased head-dipping duration, and WAY 100635, which did not affect exploratory head-dipping when administered alone, antagonized this effect. The administration of WAY 100635 significantly increased grooming behaviour, and this effect was inhibited by the two doses of CP 55,940, which did not exert any effect, per se, on this parameter. We provide the first evidence implicating 5-HT1A receptors in anxiety-related behavioural responses to a cannabinoid agonist.

[Prevalence and treatment of Gram-positive infections in internal medicine departments of Spanish hospitals: IGP Study]

This study aimed to identify therapeutic approaches and the tendencies of Gram-positive infections in Spanish hospitals in terms of prevalence, origin, location and etiology, as well as the characteristics of patients with these infections, their underlying illnesses, the severity and predisposing factors. We used statistical analysis to compare the results of two multicenter prevalence studies, the first from 1994-1995, and the second in 1998. We found a statistically significant decrease in the percentage of infected patients (45.8% vs. 32.8%; p <0.001), but an increase in infections by Gram-positive microorganisms (14.4% vs. 20.6%; p <0.001), which was reflected in the increased use of glycopeptides (17.1% vs. 31.2%; p = 0.002). The use of quinolones also increased. The most common underlying illnesses were heart disease and diabetes mellitus, and there was a reduction in the number of patients infected by HIV and in users of parenteral medication. The decrease in outpatient infections indicated that nosocomial infection was more frequent in the second study, in which the number of predisposing factors increased (52.3% vs. 79.2%; p <0.001), the most common of which were peripheral line, immobilization and a bladder catheter. Bacteremia was the most frequent infection, and there was a reduction in lower respiratory tract infections and an increase in skin and soft tissue infections. Staphylococcus aureus was the most frequently found microorganism and showed a significant increase in incidence (27.2% vs. 47.9%; p <0.001), whereas pneumococcus showed a decrease (15.0% vs. 5.2%; p = 0.012). It was concluded that despite the decrease in the percentage of infected patients and severely ill patients, there is an increase in Gram-positive infections, especially bacteremia, and in the use of more aggressive treatments. This may reflect the increase in resistant isolates.

Dopaminergic modulation of nNOS expression in the pituitary gland of male rat

Nitric oxide is an unconventional transmitter since it is not transported and released by exocytosis. In the pituitary gland, nitric oxide is locally synthesised by gonadotroph and folliculo-stellate cells. Dopamine, the principal central inhibitory signal in prolactin release, may exert its inhibitory effects by stimulation of nitric oxide production. However, the effects of dopaminergic modulation on nitric oxide-producing pituitary cells have not been analysed. Therefore, we examined the effects of intraventricular administration of the dopamine antagonist haloperidol (40 microg) on the pituitary expression of neuronal nitric oxide synthase (nNOS) in male adult rats. In untreated and control animals, nNOS-positive cells were very similar. Two types of nNOS-positive cells appeared in the pars distalis: round or polygonal cells and stellate cells. Although some isolated cells were found, the nNOS-positive cells commonly appeared grouped in clusters close to blood vessels. nNOS immunoreactivity appeared as a uniform staining throughout the cytoplasm, including cell prolongations. The number and size of nNOS-expressing cells in the pituitary gland decreased significantly after treatment with haloperidol (p<0.01). To evaluate the potential direct effect of dopamine on pituitary cells, pituitary monolayer cultures were treated with dopamine during a time-course of 12 h. Our in vitro studies revealed that dopamine increases the percentage of nNOS-positive cells and augments cellular area (p<0.05). These results demonstrate that: (1) treatment of rats in vivo with a dopamine antagonist significantly decreases expression of nNOS in the pituitary and (2) in vitro dopamine exerts a direct effect on pituitary cultures by increasing nNOS-positive cells. Thus, these findings suggest that dopamine may function as a physiological stimulator of nNOS expression in the rat pituitary gland.

Is Anisakis simplex responsible for chronic urticaria?

The association of chronic urticaria (CU) to parasitic infestations has been poorly studied. Recently, sensitization to the parasite larva Anisakis simplex has been described as the cause of acute urticaria and anaphylaxis. The aim of this work was to study the relationship between sensitization to A. simplex and CU. One hundred one patients with CU were studied. Data of possible contacts with A. simplex were collected and the usual CU study was performed. Furthermore, total and specific immunoglobulin E (IgE; Pharmacia CAP system IGE fluorescence enzyme immunoassay: CAP) to A. simplex, Ascaris lumbricoides, Echinococcus granulosus, and Toxocara canis were determined as well as skin-prick test with A. simplex and serology to E. granulosus. In accordance with the results of the CAP to A. simplex, the patients were divided into two groups, positive and negative, and, subsequently, subdivided into two other subgroups that were alternatively told to stop eating fish or seafood in their diet or to continue with their normal diet. Checkups were performed at 6, 12, and 18 months. Thirty-five percent of the patients had positive skin tests to A. simplex, and CAP to A. simplex was positive in 55%. The fish-eating habits, acute or chronic gastrointestinal disease, and the background of abdominal surgery were not related to the results of the CAP and/or skin test to A. simplex. A total of 21.8% of all the patients had detectable CAP to A. lumbricoides, 91% of whom had positive CAP to A. simplex. Three patients had specific IgE to T. canis and five patients had specific IgE to E. granulosus, in the absence of positive serology. All had specific IgE to A. simplex. Present infestation could not be proved in any of them. The clinical evolution and variations of CAP to A. simplex and of total IgE were not statistically different among the groups during the 6, 12, and 18 months of the study. The percentage of sensitization to A. simplex in patients with CU is elevated and determines the sensitization to other parasites because of cross-reactivity. We have not found any causal relationship between the presence of specific IgE to A. simplex and CU. The clinical importance of this finding in this disease is still undetermined.