Lack of clinical utility of cytomegalovirus blood and urine cultures in patients with HIV infection

OBJECTIVE

To determine the clinical significance of cytomegalovirus (CMV) blood and urine cultures in patients with human immunodeficiency virus (HIV) infection.

DESIGN

Inception cohort of patients with HIV infection and CMV culture data.

SETTING

Government referral-based research hospital.

PATIENTS

A total of 322 HIV-infected patients who had a CMV blood culture and 293 HIV-infected patients who had a CMV urine culture within 7 days of a CD4 determination.

MEASUREMENTS

Cytomegalovirus blood and urine culture results; circulating CD4 lymphocyte counts; pathologic or retinopathic findings of CMV disease.

RESULTS

Nine of 26 patients (34.6%) with CMV viremia subsequently developed CMV end-organ disease compared with 11 of 74 (14.9%) patients without viremia, (difference, 19.7%; 95% CI, -0.3% to 39.7%). Fifteen of 47 patients (31.9%) with CMV viruria developed end-organ disease compared with 4 of 43 (9.3%) patients without viruria, (difference, 22.6%; CI, 6.7% to 38.5%). Cytomegalovirus culture positivity had poor predictive value for the subsequent development of end-organ disease (35% for viremia and 28% for viruria). Further, patients with proven end-organ disease were often not viremic (45%), but most were viruric (88%). Cytomegalovirus viremia did not correlate with the presence of either fever or weight loss in this patient group. Both blood culture positivity and urine culture positivity varied inversely with the CD4 count (P = 0.0001 for both associations).

CONCLUSIONS

The likelihood that a blood or urine culture will be positive in a patient with HIV infection correlates better with immunologic status than with current or future clinical status. Although the absence of CMV viruria may suggest that CMV disease is not present, CMV blood and urine cultures have poor diagnostic and predictive value and therefore should be used primarily for research purposes or drug susceptibility testing and not for making clinical decisions.

Parkinson's dementia and Alzheimer's dementia: an evoked potential comparison

Auditory endogenous event-related potentials (ERPs) and flash visual evoked potentials (VEPs) were recorded in 26 elderly patients with idiopathic Parkinson's disease (PD), 14 with dementia and 12 non-demented, 16 elderly patients with Alzheimer dementia (AD) and 15 cognitively intact controls. ERP P3 and flash-VEP N2, P2 and delta (P2-P1) latency measures were significantly increased in the demented PD group compared with controls. The ERP P3 latency was also significantly delayed in the AD group compared with controls, but the differences in the flash-VEP measures from controls were not significant. No significant differences were noted between the PD groups, except for a significantly shorter flash-VEP N1 latency in the demented PD group; this was also the only significant evoked potential difference between the AD and PD dementia groups, which were otherwise electrophysiologically similar.

HIV and the elderly

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Longitudinal diagnosis of memory disorders

Early referral for specialist assessment is becoming more common with memory disorders and dementia: the mean Mini-Mental State Examination (MMSE) score of new patients at our clinic rose from 18.7 to 20.7 between 1986 and 1990. The clinical diagnosis of mild to moderate dementia has been recognized to be difficult, but several studies have reported cross-sectional diagnosis. We examined the number of visits required to establish a clinical diagnosis of dementia in the first 125 patients attending a Memory Disorders Clinic who had at least two visits (six months apart) and the stability of the diagnoses. Just under half of the patients required at least two visits to establish the clinical diagnosis. The MMSE was not a good guide to the number of visits required but the diagnosis at the first visit remained stable in all patients who scored < or = 10/30. Sixteen per cent of patients interchanged between the categories of Alzheimer's, mixed and vascular dementias. Possible age-associated memory impairment progressed to dementia in six of eight cases, and depression to dementia in three cases. The diagnosis of mild to moderate dementia should not be restricted to a cross-sectional approach, but should involve serial clinical, psychological and affective assessments.

Bronchial epithelial cells release neutrophil chemotactic activity in response to tachykinins

The purpose of this study was to determine whether substance P (SP), neurokinin A (NKA), and neurokinin B (NKB) induce the release of neutrophil chemotactic activity (NCA) from bovine bronchial epithelial cells (BBEC) and whether neutral endopeptidase (NEP), a membrane-bound metalloenzyme that hydrolyzes tachykinins, modulates these effects. BBEC monolayers were exposed to SP, NKA, and NKB in the absence or presence of phosphoramidon (10(-6) M), a selective NEP inhibitor, for 72 h. Using a modified blind-well in vitro neutrophil chemotaxis assay, we found that tachykinin-exposed BBEC culture supernatant fluids induced significant neutrophil chemotaxis compared with supernatants obtained from unstimulated BBEC. Maximal effect was observed after 48 h of incubation and at SP concentration of 10(-13) M [92 +/- 3 (SP) vs. 64 +/- 2 (media) cells/high-power field (HPF), mean +/- SE, n = 7, P less than 0.05]. Release of NCA was mediated by the COOH-terminal of the SP molecule. The rank order of potency of tachykinins in inducing release of NCA was SP greater than NKA = NKB. SP-induced response was significantly potentiated by phosphoramidon (109 +/- 3 vs. 92 +/- 3 cells/HPF, n = 7, P less than 0.05), whereas other proteinase inhibitors had no effect. The released NCA was composed of protein and lipid-soluble components. These data indicate that mammalian tachykinins induce the release of NCA from BBEC and that NEP modulates these effects. We suggest that tachykinins regulate neutrophil recruitment into the lower respiratory tract, in part, by inducing the release of NCA from airway epithelial cells.

Current uses of ophthalmic lasers

Current laser treatments are quick, relatively painless, and well tolerated. Some ophthalmic techniques can be performed only by laser while others have a lower morbidity than alternative treatments. Peripheral retinal photocoagulation and focal photocoagulation now offer greatly improved visual prognosis for diabetic patients with proliferative diabetic retinopathy or diabetic macular disease. Selected cases of macular degeneration may be treated by focal laser photocoagulation. The role of lasers in treating sub-retinal neovascular membranes is limited by the extent and location of the membrane at presentation and the high risk of recurrence after treatment. Patients with distorted vision must be referred urgently for specialist ophthalmic assessment. Flat retinal holes and tears may be sealed by laser therapy, thus preventing retinal detachment. Short pulsed neodymium-YAG photodisruptive capsulotomy effectively clears the visual axis of thickened posterior lens capsule after cataract surgery. Short pulsed neodymium-YAG photodisruptive iridotomy may be used to treat and prevent angle closure glaucoma. Laser trabeculoplasty aids the control of open angle glaucoma. Research is continuing into the role of other lasers in managing open angle glaucoma and of photoablative lasers in treating refractive errors and superficial corneal disorders.

Dementia and Driving

Many European countries test cars, but not their drivers, as they age. There is evidence to suggest that human factors are more important than vehicular factors as causes of motor crashes. The elderly also are involved in more accidents per distance travelled than middle-aged drivers. As the UK relies on selfcertification of health by drivers over the age of 70 years, we examined the driving practices of patients with dementia attending a Memory Clinic. Nearly one-fifth of 329 patients with documented dementia continued to drive after the onset of dementia, and impaired driving ability was noted in two-thirds of these. Their families experienced great difficulty in persuading patients to stop driving, and had to invoke outside help in many cases. Neuropsychological tests did not help to identify those who drove badly while activity of daily living scores were related to driving ability. These findings suggest that many patients with dementia drive in an unsafe fashion after the onset of the illness. The present system of selfcertification of health by the elderly for driverlicencing purposes needs to be reassessed.

Spinal fusion for back pain: a clinical and radiological review

Eighty-one patients who had spinal fusions performed for back pain over a 7-year period were reviewed; 74% were satisfied with the outcome of their surgery, mainly because of the degree of pain relief obtained. Based on lateral radiographs of the fusion area in flexion and extension, there was a 34% pseudarthrosis rate in first-time fusions. However, there was no clear relationship between the integrity of fusion and clinical success, indicating that many factors other than bony fusion influence the eventual outcome of the operation.

Physicians, elderly drivers, and dementia

In western countries, the proportion of drivers who are elderly is increasing rapidly; over a quarter of the driving population will be 55 years of age or older by the year 2000. Although elderly drivers tend to drive less and may avoid night driving, the number of car accidents and the severity of injuries sustained in such accidents by distance driven increases strikingly after the age of 65. But how can doctors identify those elderly drivers who are a danger to themselves and others? And, once they are identified, how should clinicians balance the effects of removing a driving licence, which may greatly affect a patient's lifestyle, against public safety and breach of confidentiality if the patient refuses to give up his or her licence voluntarily? Medical decisions about illnesses that predispose to loss of consciousness are fairly clear-cut, but normal ageing processes and dementia can be much more difficult to identify and to assess; moreover, there seems little correlation between tests of mental performance and driving ability. Comparisons between practices in different countries may provide some answers, but the introduction of modified driving tests for elderly drivers with some evidence of mild impairment but who wish to retain their driving licence should be considered.

A preliminary evaluation of 566C80 for the treatment of Pneumocystis pneumonia in patients with the acquired immunodeficiency syndrome

BACKGROUND

The drug 566C80 is an investigational hydroxynaphthoquinone that is active against Pneumocystis carinii in vitro and in animal models. Initial studies in humans indicate that 566C80 is safe and has adequate bioavailability after oral administration.

METHODS

We conducted an open-label trial of 566C80 in 34 adults with the acquired immunodeficiency syndrome (AIDS) and untreated pneumocystis pneumonia. All the patients had a partial pressure of arterial oxygen of at least 60 mm Hg while breathing room air. They were enrolled sequentially in three cohorts taking 566C80 at different dosages, all administered orally: 750 mg three times daily for 5 days, then twice daily for 16 days; 750 mg three times daily for 21 days; and 750 mg four times daily for 21 days.

RESULTS

All 34 patients survived, and 27 (79 percent) were successfully treated with 566C80 alone. The mean partial pressure of oxygen in 33 patients was 78 mm Hg at entry and 93 mm Hg after the course of 566C80 (P less than 0.001). In five patients (15 percent) the drug was discontinued because of lack of response. In four patients (12 percent), the drug was discontinued because of toxicity (fever and rash in two patients each). In two of these, treatment was considered to have succeeded because 566C80 was not discontinued because of toxicity until after day 14. Five of the successfully treated patients had rashes that resolved despite continued therapy. In nine patients, serum alanine aminotransferase levels rose above 100 U per liter. During the first three months after the completion of therapy, pneumocystis pneumonia recurred in 4 of the 27 successfully treated patients, and another 3 patients had recurrences between month 3 and month 6 of follow-up. The mean (+/- SEM) steady-state plasma levels of 566C80 were similar in the three cohorts: 16.3 +/- 2.10, 20.4 +/- 2.48, and 18.9 +/- 3.08 micrograms per milliliter in the patients taking the drug twice daily, three times daily, and four times daily, respectively.

CONCLUSIONS

From these preliminary data, the investigational compound 566C80 appears to be a safe, effective, and well-tolerated therapy for P. carinii pneumonia of mild-to-moderate severity in patients with AIDS.

A DNA-binding factor in adult hematopoietic cells interacts with a pyrimidine-rich domain upstream from the human delta-globin gene

To date, DNA-binding factors with a developmental pattern of expression have not been described in human erythroid cells to explain the switch from fetal (gamma-) to adult (delta- and beta-) globin gene expression. Here we describe a factor present in nuclear extracts from adult mouse and human hematopoietic cells that binds to an oligopyrimidine repeat approximately 960 base pairs upstream from the human delta-globin gene. The binding site for the factor is within an unusual 250-base-pair domain that is greater than 95% pyrimidines on one strand. This domain is preferentially sensitive to S1 nuclease in supercoiled plasmids, indicating that it can adopt an alternative non-B-DNA conformation. A number of S1-sensitive sites within the domain, including the factor-binding site, have sequence characteristics associated with the formation of a triple helix (H-DNA). The position of the binding site between the fetal and adult beta-globin-like genes, its potential for adopting an unusual secondary structure, and the restricted activity of the binding factor to adult hematopoietic tissues suggest possible roles in hematopoietic cell development and hemoglobin switching.

Attitudes of nursing and rest home administrators toward deinstitutionalized elders with psychiatric disorders

The administrators of 92 nursing homes and rest homes in western Massachusetts were surveyed on their experiences with elderly residents with a history of psychiatric hospitalization and their willingness to admit such individuals in the future. A majority of those who had admitted deinstitutionalized elders with chronic psychiatric disorders reported having experienced severe problems with them. Most of the problems involved the resident going into crisis or producing some highly disruptive behavior. Although two-thirds of the facilities had admitted elders who had been deinstitutionalized from a public psychiatric hospital, only one-quarter clearly planned to do so in the future. Three quarters of the administrators reported that they did not have the support services that the deinstitutionalized elders in their facilities needed. A comparison of the services reported to be important and those reported to be available suggest that simply increasing the availability of psychiatric support services would probably not influence administrators to admit elders with chronic mental illness in the future.

Pulmonary peptides, norepinephrine and endocrine cells in monocrotaline pulmonary hypertension

The concentrations of norepinephrine and of the peptides bombesin, calcitonin gene-related peptide and neurotensin were measured in rats with monocrotaline pulmonary hypertension. The numbers of pulmonary endocrine cells showing positive immunoreactivity for calcitonin, calcitonin gene-related peptide, protein gene product 9.5 and bombesin were counted in a second group of rats with monocrotaline pulmonary hypertension. The concentration of norepinephrine in the lungs decreased significantly in the test rats but this could be attributed to dilution by an increased mass of tissue. The pulmonary concentration of all three peptides showed a decrease in the rats treated with monocrotaline but this was highly significant only in the case of bombesin. The pulmonary content of bombesin showed a substantial and significant decrease in the test rats. No neuroendocrine cells immunopositive for bombesin were identified in any of the control or test rats. There was no difference between the control and test rats with respect to the form or distribution of the cells immunoreactive for the other three The lack of pulmonary endocrine cells showing immunoreactivity for bombesin may be related to the absence of intimal proliferation in the pulmonary arteries in this species. This is in striking contrast to what occurs in plexogenic pulmonary arteriopathy in man and suggests that monocrotaline-induced pulmonary hypertension in rats is not a good animal model for this disease.

Evaluation of the PEP mask in cystic fibrosis

Twenty-eight patients suffering from cystic fibrosis, with an age range of 8-21 years entered a randomised cross-over trial to study the efficacy of the Positive Expiratory Pressure (PEP) mask as a method of chest physiotherapy, both on its own and in conjunction with other physiotherapy techniques. Twenty-four of these patients completed the trial consisting of 4 treatment programmes each lasting one month and with no wash-out period between them. Five of these patients went on to a fifth programme of Forced Expiratory Technique (FET) alone. At the end of the trial, no significant difference was found between the programmes as regards growth, Shwachman score, Chrispin-Norman score or pulmonary function tests. Twenty-three patients chose to continue using the PEP mask in conjunction with FET long-term as their chest physiotherapy programme as they felt it was an effective treatment allowing increased independence, with postural drainage being kept to a minimum.

The regulation of gamma-globin gene expression

In summary, our analysis indicates that important sequences for the proper initiation of fetal gene transcription in fetal cells are located in the gamma-globin [sequence: see text] promoter. These sequences are sufficient for tissue-specific expression but not induction in K562 cells. Sequences in the gamma-globin IVS-2 and the beta-globin 3' enhancer increase gamma beta and gamma-Neo transcripts when cells containing these genes undergo erythroid maturation as measured by induction with hemin. The mechanism by which these sequences exert their effect remains to be elucidated. [see text] Multiple protein factors bind to both the gamma promoter and the beta 3' enhancer. Both of these regions contain binding sites for the erythroid-specific factor NFE-1 and the octamer binding factor OTF-1. In the gamma upstream region, there may be a competition between OTF-1 binding and NFE-1 binding that affects gamma gene regulation. Our results indicate that the beta 3' enhancer interacts with the gamma gene promoter to permit increased gamma gene expression. We have developed a model for globin gene switching that takes into consideration the effect of cis-acting sequences on globin gene transcription. A similar model of hemoglobin switching in chickens has been proposed by Choi and Engel. In our model, competition for the beta-globin 3' enhancer is involved in stage-specific transcriptional activation of gamma-globin genes in fetal cells and beta-globin genes in adult cells. In adult cells the protein-protein interactions between adult cell-specific factors interacting with the beta-globin promoter and erythroid-specific factors interacting with the beta 3' enhancer would activate transcription of the beta-globin gene. In fetal cells protein-protein interactions between fetal cell-specific factors interacting with the gamma-globin promoter and erythroid-specific factors interacting with the beta 3' enhancer would activate the transcription of the gamma-globin genes.

Herniated lumbar disc in patients over the age of fifty

Fifty patients ranging in age between 50-78 years (mean, 56) underwent surgery for a herniated lumbar disc between January 1986 and July 1988. All had objective clinical and radiographic evidence of a herniated disc. All had had failure during an appropriate period of conservative treatment. Far lateral herniation occurred in 8%, and 28% had disc herniations at L2 or L3. Surgical results were 64% excellent, 28% good, 6% fair, and 2% poor. Complications including urinary tract infection, wound infection, myocardial infarction, and pulmonary embolism were observed in 8% of patients. Lumbar disc herniation in the elderly is common. After thorough evaluation to exclude neoplasm or infection, decompression of neural structures can lead to 90% good to excellent results. Spinal stenosis must be carefully considered both preoperatively and intraoperatively. Also, a higher incidence of more cephalad lumbar herniations and far lateral herniations was observed in older patients.

Protein-DNA interactions upstream from the human A gamma globin gene

We have used DNAase I footprinting and the gel mobility shift assay to study proteins which bind to promoter elements located between -140 and -382 upstream of the human A gamma globin gene. Footprints are found with both erythroid and nonerythroid nuclear extracts at three sites: from -294 to -264, -242 to -227, and -189 to -172 from the transcription initiation site. An erythroid-specific footprint is identified from -194 to -189. We demonstrate that two known transcription factors, the ubiquitous octamer-binding protein OTF-1 and the erythroid regulatory factor NFE-1, bind to the -194 to -172 region and that their footprints overlap. Binding of OTF-1 to this region is reduced by a mutation at -175 associated with a form of non-deletion hereditary persistence of fetal hemoglobin. We conclude that OTF-1 may compete with NFE-1 for the -175 binding site, possibly functioning as a repressor of gamma globin transcription.

Elder abuse

Elder abuse is an under-recognised cause of morbidity in the elderly. The frail elderly with multiple physical and psychiatric problems living with a relative who may also have a physical or psychiatric problem are particularly at risk. Although increased awareness of the problem and a high index of suspicion are necessary factors to diagnose the condition, clinical pointers towards diagnosis are available. Treatment for both victim and "carer" should be on the basis of multi-disciplinary assessment, and may result in admission of the elderly patient to an extended-care facility.

The effect of mild to moderate dementia on the Geriatric Depression Scale and on the General Health Questionnaire

The Geriatric Depression Scale (GDS) and two versions of the General Health Questionnaire (GHQ 28 and corrected GHQ 28) were administered to 111 patients admitted to an acute geriatric medical unit. Depression and dementia were diagnosed by semi-structured interview using DSM III criteria. There was no statistically significant difference in the three scales between cognitively normal depressed patients and demented depressed patients. The three scales were sensitive indicators of depressive illness (greater than 90%), but the GHQ 28 and CGHQ 28 needed adjustment of their community-based threshold values.

Regulation of human fetal hemoglobin gene expression

An understanding of the mechanism involved in the regulated expression of the human gamma and beta globin genes requires the detailed definition of the cis-acting DNA sequences and trans-acting protein factors responsible for their developmental stage specific expression. To determine the critical cis-acting elements, hybrid genes containing elements of the gamma and beta globin genes were transfected into K562 cells, a human erythroleukemia line. The regulated expression of the gamma and beta genes was also studied by transferring hybrid genes containing the gamma or beta promoters linked to the neomycin resistance gene (neoR) into erythroid (K562) cells and nonerythroid (Hela) cells. DNA sequences found to be important to the expression of the gamma gene were assayed for the presence of transacting factors by studying the binding of protein factors using the gel mobility shift assay. The results suggest that there are multiple cis-acting elements 5' and 3' to the gamma and beta genes, and perhaps within these genes contributing to their regulation. In addition, there are multiple trans-acting protein factors interacting with these regions which may determine their transcriptional regulation in erythroid cells.

Screening for dementia and delirium using an adapted Folstein Mini-Mental State Examination

An adapted Folstein Mini-Mental State Examination was applied to 244 consecutive admissions to an acute geriatric medical unit to determine the prevalence of cognitive impairment. At a cut-off point of 23/30, 109 (44%) were rated as normal and 44 (19%) were unable to perform the test. Of the 85 (36%) who scored less than 23, 63 were suffering from dementia, nine were delirious, and 12 had normal cognitive function, a false positive rate of 14%. The most common dementia was senile dementia of the Alzheimer type. Cognitive impairment was not noted by the admitting doctor in 57% of affected cases. The need for increased awareness of cognitive impairment in the elderly is emphasized, and the more widespread use of formal mental test scores is recommended.

Regulation of fetal globin gene expression in human erythroleukemia (K562) cells

We have analyzed the transcription and induction of fusion globin genes comprised of portions of either gamma and beta globin sequences or gamma and neomycin resistance gene sequences. The analysis of gamma promoter beta and gamma-neo fusion genes indicates that 5' gamma flanking sequences are sufficient for tissue specific expression but not induction in K562 cells. A beta gene containing only the substitution of gamma IVS 2 for beta IVS 2 is expressed and induced when transcripts are analyzed with a 3' probe in contrast to the lack of expression seen with an intact beta gene. Thus, fusion globin genes containing gamma IVS 2 are both expressed and induced indicating that this region may be involved in the response to hemin stimulation, however, the mechanism is unclear. A gamma-neo fusion gene containing the gamma 5' region is expressed but not induced. When an EcoRI-Bg1 II fragment containing the beta 3' enhancer is ligated downstream of the gamma-neo gene this gene is now inducible. Multiple genetic elements are involved in the regulated expression of gamma genes in fetal erythroid cells. These experiments begin to localize these sequences to specific regions within the gamma globin gene.

A method to determine the true angulation of long bone deformity

A new method of geometrical analysis is capable of determining bone deformity from routine anteroposterior (AP) and lateral roentgenograms. The maximum angulation may occur in a plane other than the AP or lateral roentgenogram planes. Therefore, the maximum angulation may exceed the apparent angulation seen on routine AP and lateral views. The AP and lateral views will underestimate the true angulation most when the angulation seen on the AP and lateral views is similar.

Chronic vascular pulmonary dysplasia associated with neonatal hyperoxia exposure in the rat

Chronic sequelae of neonatal hyperoxia was studied in male rats exposed to 0.96-1.0 FiO2 for the first 8 days of life. At 58 days of age functional and morphologic cardiopulmonary changes were compared with controls. Right ventricular systolic pressure was measured percutaneously under anesthesia and was increased in the O2 group (29.5 mm Hg +/- 3.1 versus 23.2 mm Hg +/- 3.5, p less than 0.001). Lung and heart weights were similar between groups. Right ventricular weights however were increased in the O2 group (0.197 g +/- 0.023 versus 0.175 g +/- 0.020, p less than 0.001). Air pressure-volume curves were similar but in the O2 rats saline deflation curves were shifted left and maximal fluid lung volumes were greater (14.1 +/- 1.2 versus 12.0 +/- 0.7 ml, p less than 0.001). Pulmonary arteries were perfused at 100 cm H2O with a barium-gel mixture and lungs were fixed at 25 cm H2O with formalin. Microscopic examination of lungs revealed dysplastic changes of alveolar architecture which included irregularly enlarged alveoli and incomplete alveolar septation. Morphometric studies of the lungs showed that the O2 rats had an increased volume proportion of parenchyma (0.865 +/- 0.020 versus 0.850 +/- 0.019, p less than 0.05), increased mean linear intercept (72.3 microns +/- 9.5 versus 53.6 microns +/- 5.0, p less than 0.001), decreased number of alveoli per mm2 (207 +/- 34 versus 319 +/- 39, p less than 0.001) and fewer small arteries (20-200 microns) per mm2 (8.7 +/- 1.3 versus 14.9 +/- 2.4, p less than 0.001). The number of small arteries/100 alveoli was similar.(ABSTRACT TRUNCATED AT 250 WORDS)

Myocardial infarction and the normal arteriogram--possible role of viral myocarditis

In a prospective study we identified a group of 12 patients diagnosed as having acute myocardial infarction but with electrocardiographic features of non-transmural infarction and serological evidence of recent Coxsackie B infection favouring the possibility of myocarditis. The group included 9 females and 3 males, aged from 38-60 y. Coronary arteriography was carried out in 11 patients. Eight of the 11 patients showed no significant (greater than or equal to 50%) coronary arterial obstruction. We suggest that coronary artery disease did not contribute to the clinical presentation in the majority of these patients and that the likely diagnosis was viral myocarditis in at least 6 of them. We conclude that viral myocarditis may simulate myocardial infarction and contribute to the uncommon but controversial syndrome of myocardial infarction with a normal coronary arteriogram.