[Phenomenologic analysis of somatic symptoms in melancholia]

Our presentation is exclusively concerning << somatic >> symptoms, for which non organic basis has been found as yet, which therefore are pure symptoms of bodily experience. As localised disturbances of bodily sensations (cenestopathies) of melancholics they are not only differentiated from somatic symptoms in the above mentioned narrow sense but also from the somatizing syndrom as well as from hypochondria. They can also be differentiated from disturbances of bodily sensations of schizophrenics. Our phenomenological analysis does not only ask for the descriptive phenomenology of these symptoms but also for the << logos >>, i.e. the essence of these phenomena. With the aid of this phenomeno-<< logical >> analysis these disturbances of bodily sensations are seen as a special kind of depersonalisation what we call a melancholic depersonalisation.

Autoimmune thyroid disease in primary Sjögren's syndrome

PURPOSE

To evaluate the prevalence of autoimmune thyroid disease and thyroid dysfunction in patients with primary Sjögren's syndrome.

PATIENTS AND METHODS

Thyroid function of 33 patients with primary Sjögren's syndrome was clinically and biochemically evaluated. Thyroid hormones and autoantibodies against thyroid peroxidase, thyroglobulin, and thyroid hormones were measured.

RESULTS

Autoimmune thyroid disease and thyroid dysfunction were found in 15 cases (45%): autoimmune thyroiditis in 8 (24%); autoimmune hyperthyroidism in 2 (6%); and reversible iodine-induced hypothyroidism in the remaining 5 (15%). One or more of the evaluated autoantibodies were detected in 8 euthyroid patients (24%). Overall, the prevalence of autoantibodies against thyroid peroxidase, thyroglobulin, thyroxine, and triiodothyronine was 45%, 18%, 42%, and 36%, respectively.

CONCLUSIONS

The high prevalence of autoimmune thyroid disease and thyroid dysfunction found in primary Sjögren's syndrome, using sensitive immunologic and thyroid function tests, suggest that both diseases are more frequently associated than it was previously thought, and should be sought clinically and by laboratory tests in all patients with primary Sjögren's syndrome.

Cloning, expression and functional analyses of the catabolite control protein CcpA from Bacillus megaterium

A mutant of Bacillus megaterium relieved from catabolite repression has been used to clone ccpA from B. megaterium by complementation. ccpA is the first gene of a presumed operon, in which it is followed by the motA homologue ORF1 and the motB homologue ORF2. The mutation maps in the 3'-terminal region of ccpA, where an in-frame duplication of 84 nucleotides located between two 9 bp direct repeats leads to an insertion of 28 amino acids near the C-terminus of CcpA. An in-frame deletion of 501 bp in ccpA exhibits the same phenotype as the 84 bp duplication. Deletion of ORF1 and ORF2 does not yield an apparent phenotype. A single-copy ccpA::lacZ transcriptional fusion is constitutively expressed, independent of whether the growth medium triggers catabolite repression or not. The ccpA mutation leads to relief of catabolite repression exerted by glucose, fructose, mannitol, glucitol and glycerol, whereas only smaller effects were found with ribose, citrate and glutamate. The respective growth rates on these carbon sources are uniformly reduced to a generation time of about 90 min in the ccpA mutant. Catabolite repression of a plasmid-encoded xylA::ccpA fusion is less efficient than that of a xylA::lacZ fusion in the same vector. Furthermore, overproduction of CcpA decreases catabolite repression of a single-copy xylA::lacZ fusion approximately twofold. Thus, overexpression of CcpA may be counterproductive for catabolite repression, supporting the hypothesis that CcpA by itself may not bind sufficiently strongly to the cis-active catabolite-responsive element to exert catabolite repression.

[Euthanasia: compulsory reflection]

Euthanasia should be considered one of the main philosophical topics of today's medical practice. In view of the technological advances in medicine, the economic pressure in the majority of our medical systems, and a deep alteration and modification in the patient-physician relationship, the status of some patients in their final days should be reconsidered. The increased awareness of the public about euthanasia and related topics (pain, assisted suicide, dying with dignity, etc.) suggests that a urgent dialogue between lay persons and physicians is needed.

Psychotherapy based on identity problems of depressives

I present here what I call my identity-theoretical concept of depression, discussing both bipolar disorders and major depressive disorders. The method is phenomenological in that through interviews with depressives we become aware of their being-in-the-world, their social roles and the various identities they form through identification and under the pressure of their environment. In contrast to the normal individual, whose identity is autonomous, flexible, and continuously changes throughout the life cycle, depressives have what I call an "overidentifying" identity formation. That is to say, they cannot stand back and be autonomous, they must overidentify or throw themselves excessively into whatever particular social expectations they encounter. This leads to an "overadjustment" to the norms of society, a rigidity, and an excessive dependence on others. Patients in the manic phase may show the opposite extreme in their effort to avoid the overidentification tendency. Furthermore, depressives cannot tolerate ambiguity, they cannot deal with the positive and negative characteristics in one or the same object or person. Depressive or manic episodes are precipitated by situations where ambiguity cannot be avoided, or where conflicting identities are demanded at the same time, for example when a high quantity of high quality work is demanded in too short a time for this to be possible. Any sort of changes or role losses that demand flexibility of one's identity or the capacity to step back a bit and suspend one's characteristic habits or identity manifestations will precipitate manic or depressive episodes in such predisposed melancholics. On the basis of my identity-theoretical concept certain guidelines for psychotherapy suggest themselves, and these are presented. I call this "identity therapy," and I distinguish it from cognitive therapy because it is not the cognitive schemes that are disturbed in these patients but rather their identity structure. I discuss separately the guidelines for treatment in the acute and in the rehabilitation phase of the illness. In the former I suggest helping the depressive accept the role of patient in order to relieve the pressure of sociologic conflicting expectations on the patient's brittle identity concept. It is important for the patient to be able to resume social roles and routine activities, beginning in an anxiety-free setting where ego-satisfying achievements are encouraged. In the rehabilitation phase self-reflection is more encouraged, with the patient achieving an understanding of what has precipitated the episode of the illness in terms of the overwhelming of the patient's identity concept.(ABSTRACT TRUNCATED AT 400 WORDS)

Visceral larva migrans mimicking rheumatic diseases

OBJECTIVE

To report rheumatologic or rheumatologic-like manifestations of the visceral larva migrans (VLM) syndrome.

METHODS

We carried out a prospective study of patients with VLM seen in a private practice setting in Mexico City between 1990 and 1993.

RESULTS

From a population of 600 patients we identified 6 patients (5 women) with VLM. Three patients complained of arthralgia; in 4 a history of migratory cutaneous lesions was elicited, and in one monoarthritis of the right knee was found. One patient had deep edema that suggested thrombophlebitis of the right arm; the man in our series had right testicular swelling during followup. In 2 cases, panniculitis was documented by biopsy and in one, small vessel vasculitis. Four patients had frequent contact with dogs and one with cats; 4 patients frequently ate raw fish. The diagnosis of VLM was confirmed either by the clinical picture, biopsy, or ELISA:

CONCLUSION

The spectrum of rheumatological manifestations in VLM may be wider than previously thought.

Sequences of ccpA and two downstream Bacillus megaterium genes with homology to the motAB operon from Bacillus subtilis

A regulatory gene with 69% nucleotide sequence identity to the Bacillus subtilis ccpA was cloned from Bacillus megaterium by complementation of a mutant relieved of catabolite repression. Sequencing of the gene and its adjacent regions revealed two additional open reading frames (ORFs) downstream from ccpA. These three genes are presumably in one operon. ORF1 and ORF2 show homology to two genes downstream from ccpA in B. subtilis, as well as to the B. subtilis motA and motB genes, respectively.

Listeriosis in patients with connective tissue diseases

OBJECTIVE

Patients with connective tissue diseases (CTD) are prone to infections, either from the disease itself or secondary to treatment. The incidence of listeriosis in immunosuppressed patients is increasing. We therefore evaluated the frequency of listeriosis, an otherwise rarely reported infection in the rheumatologic literature, in patients with CTD.

METHODS

Retrospective analysis of listeria positive cultures in patients with CTD between 1982 and 1992 at a tertiary care center in Mexico City.

RESULTS

We identified 8 patients: 7 with systemic lupus erythematosus and one with dermatomyositis. At the time of the infection, 5 had active disease, 6 were receiving prednisone and/or other immunosuppressive drugs and 2 were receiving hemodialysis. L. monocytogenes was isolated from cerebrospinal fluid (5 patients), from blood (one patient) and from both sites (2 patients). Patients had bacteremia without a known focus of infection or meningitis as the 2 most common clinical forms of listeriosis. In spite of appropriate antibiotic therapy, 4 patients died.

CONCLUSION

As in other immunosuppressed individuals, listeriosis is an aggressive infection in patients with CTD. Although rare, listeriosis should be included in the differential diagnosis of meningitis in patients with CTD and appropriate aggressive therapy rapidly instituted. To determine its frequency in rheumatic patients, multicentric prospective studies are required.

Myositis in primary Sjögren's syndrome. Report of 3 cases

OBJECTIVE

To describe the findings and course of myositis in primary Sjögren's syndrome (SS).

METHODS

We studied myositis in SS when clinically indicated. Of 104 patients with SS, we identified 3 cases. In all, the diagnosis was made according to clinical data, biochemical, electromyographic and biopsy criteria. Other autoimmune diseases were excluded.

RESULTS

We found a prevalence of 3% of myositis secondary to SS. There were no significant associations between myositis and other clinical or laboratory variables.

CONCLUSION

Although rare, myositis must be considered a part of the spectrum of SS. In our experience, treatment with steroids and immunosuppressive drugs was successful.

Catabolite repression of the Bacillus subtilis xyl operon involves a cis element functional in the context of an unrelated sequence, and glucose exerts additional xylR-dependent repression

Catabolite repression (CR) of xylose utilization by Bacillus subtilis involves a 14-bp cis-acting element (CRE) located in the translated region of the gene encoding xylose isomerase (xylA). Mutations of CRE making it more similar to a previously proposed consensus element lead to increased CR exerted by glucose, fructose, and glycerol. Fusion of CRE to an unrelated, constitutive promoter confers CR to beta-galactosidase expression directed by that promoter. This result demonstrates that CRE can function independently of sequence context and suggests that it is indeed a generally active cis element for CR. In contrast to the other carbon sources studied here, glucose leads to an additional repression of xylA expression, which is independent of CRE and is not found when CRE is fused to the unrelated promoter. This repression requires a functional xylR encoding Xyl repressor and is dependent on the concentrations of glucose and the inducer xylose in the culture broth. Potential mechanisms for this glucose-specific repression are discussed.

Raynaud's phenomenon in primary Sjögren's syndrome. Association with other extraglandular manifestations

One hundred and four patients with primary Sjögren's syndrome (SS) were evaluated for the presence (29%) or absence of Raynaud's phenomenon (RP). The clinical course of RP was, in general, benign and caused no vascular sequelae. In patients with primary SS having RP, nonerosive arthritis, vasculitis and pulmonary fibrosis were significantly more frequent than in those without RP. Myositis also appeared more frequently associated with RP, but the difference reached statistical significance only when combined in meta-analysis with 2 other comparable series. There were no differences in the autoantibody profiles of the 2 groups.

Salmonella arizona arthritis and septicemia associated with rattlesnake ingestion by patients with connective tissue diseases. A dangerous complication of folk medicine

Snakes constitute the main reservoir of Salmonella arizona, which are opportunistic pathogens in patients with serious underlying diseases. The 2 may meet when such patients ingest uncooked snake flesh, most often as a folk remedy for arthritis or other conditions. We have seen 11 patients in whom Salmonella arizona infection was documented. Six had systemic lupus erythematosus and another had dermatomyositis and are described in detail. All 7 had received prednisone, which was combined with azathioprine in 3. Five developed septic arthritis, including the site of a hip prosthesis in one patient. A history of dessicated rattlesnake ingestion as a "natural" remedy in either capsule or powder form was obtained in all but one of the 7 patients. Patients often think that if natural or folk remedies are not helpful they also are not harmful and, therefore, safe and worth trying. We disprove that belief and call attention to the perils of one such remedy: dessicated rattlesnake, particularly when ingested by patients with connective tissue diseases who may be immunocompromised.

Fever in adult onset Still's disease. Response to methotrexate

Four patients who fulfilled criteria for adult onset Still's disease were treated sequentially with increasing doses of acetylsalicylic acid, nonsteroidal antiinflammatory drugs (NSAID) and prednisone to control their fever and systemic manifestations. Persistence of the fever led us to treat them with small doses of methotrexate (MTX) with excellent response. Low dose MTX should be considered in patients unresponsive to antiinflammatory drugs before using high doses of prednisone.

Air esophagogram and intestinal pseudoocclusion in a patient with scleroderma

Air in the esophagus is unusual because it is collapsible. Its finding on a chest roentgenogram, particularly when not associated with a fluid level indicative of stricture, should strongly suggest systemic sclerosis (scleroderma). We describe a patient with scleroderma with intestinal pseudoocclusion and an air esophagogram. Study of chest roentgenograms of 83 patients with scleroderma, including those of 7 with pseudoocclusion, revealed no other instance of air esophagogram. This radiological sign, although rare, should suggest scleroderma and may be particularly useful in patients with "systemic sclerosis sine scleroderma."

Diabetes insipidus secondary to Wegener's granulomatosis: report and review of the literature

We describe a 51-year-old woman with Wegener's granulomatosis who developed diabetes insipidus 7 months after the onset of her granulomatous disease and despite apparently good clinical response to prednisone and trimethoprim-sulphametoxazole treatment. A brain computerized tomographic scan taken soon after the onset of polyuria disclosed an enlarged pituitary gland that completely returned to its normal size after 5 months of cyclophosphamide therapy. We review 6 other published cases of diabetes insipidus secondary to Wegener's granulomatosis and discuss the potential pathogenetic mechanisms of this rare combination.