In-111 labeled leukocyte scintigraphy in a case of multifocal candidiasis

The value of indium-111 labeled leukocyte scintigraphy for the diagnosis of infection in the general population is well documented; there is less information available on its role in the evaluation of the immunocompromised patient. In this study, leukocyte scintigraphy was performed on a 31-year-old immunocompromised woman who had a possible intra-abdominal abscess. No abscess was detected, but intense oral, esophageal, gastric, and vaginal uptake was observed. Candida infection was histologically confirmed at all four sites.

Appearance of acute gouty arthritis on indium-111-labeled leukocyte scintigraphy

Indium-111-labeled leukocyte scintigraphy was performed on a 66-yr-old male with polyarticular acute gouty arthritis. Images revealed intense labeled leukocyte accumulation in a pattern indistinguishable from septic arthritis, in both knees and ankles, and the metatarsophalangeal joint of both great toes, all of which were involved in the acute gouty attack. Joint aspirate as well as blood cultures were reported as no growth; the patient was treated with intravenous colchicine and ACTH for 10 days with dramatic improvement noted. Labeled leukocyte imaging, repeated 12 days after the initial study, revealed near total resolution of joint abnormalities, concordant with the patient's clinical improvement. This case demonstrates that while acute gouty arthritis is a potential pitfall in labeled leukocyte imaging, in the presence of known gout, it may provide a simple, objective, noninvasive method of evaluating patient response to therapy.

Indium-111-labeled leukocyte scintigraphy in hemodialysis access-site infection

Bacterial sepsis, a significant complication of chronic hemodialysis, is generally the result of infection at the vascular access site. We retrospectively reviewed the utility of indium-111-(111In) labeled autologous leukocyte scintigraphy in 26 patients (30 scans) with synthetic vascular grafts, on chronic hemodialysis, in whom hemodialysis access site infection was a diagnostic consideration. Leukocyte scintigraphy correctly identified all fifteen access-site infections; there was one false-positive study, for an overall sensitivity and specificity of 100% and 93%, respectively. Of particular significance is the fact that in nine (60%) of the fifteen access-site infections, physical examination was normal. Our data indicate that 111In-labeled leukocyte scintigraphy is a useful procedure for the diagnosis of hemodialysis access-site infection, and it is especially valuable when physical examination of the access site is normal.

SPECT imaging in the diagnosis of Budd-Chiari syndrome

We recently performed planar and single photon emission computed tomographic (SPECT) liver/spleen scintigraphy in a patient with Budd-Chiari syndrome. While planar imaging revealed only nonspecific hepatocellular dysfunction, tomographic images demonstrated increased radiotracer accumulation in the caudate lobe of the liver, the classical scintigraphic finding in this entity. This case suggests that SPECT may enhance the sensitivity of the scintigraphic diagnosis of this uncommon condition, especially when the occlusion of the hepatic veins is incomplete.

Role of endogenous cholecystokinin on vagally stimulated pancreatic secretion in dogs

Pancreatic exocrine secretion was evoked by electrical stimulation of the vagus nerves (EVS) in dogs to determine whether a gut hormone was responsible for the pancreatic stimulatory activity. In 39 dogs, pancreatic juice was continuously collected to measure volume, bicarbonate, and amylase output, while portal and femoral venous plasma concentrations of gastrin, cholecystokinin (CCK), vasoactive intestinal polypeptide (VIP), and pancreatic polypeptide (PP) were determined by radioimmunoassay. EVS produced a significant increase in the pancreatic secretion. Although concentrations of all four peptides significantly increased in plasma, only CCK at the concentration in venous circulation was bioactive in dispersed rat pancreatic acini preparations. This bioactivity of CCK was completely blocked by CR 1409, a CCK-receptor antagonist. The pancreatic secretion by EVS was reduced significantly by intravenous MK-329 (formerly L364,718) to as low as 22% of control values and was completely suppressed by intravenous atropine. The increment in plasma CCK by EVS was also significantly suppressed by atropine. The present study indicates that increased pancreatic secretion by EVS is in part mediated by endogenous CCK.

Acute effects of radiation therapy on indium-111-labeled leukocyte uptake in bone marrow

We recently performed [99mTc]MDP bone and 111In-labeled leukocyte scintigraphy on a patient receiving radiation therapy to the lower cervical and upper thoracic spine. While the bone images revealed only minimally increased activity in the radiation port, leukocyte images revealed diffuse, intensely increased uptake in this same region. Radiation therapy should be included in the differential diagnosis of increased bone marrow activity on 111In leukocyte images.

Serial dacryoscintigraphy before and after treatment with pseudoephedrine

Radionuclide dacryoscintigraphy is an accurate physiologic method for evaluating the nasolacrimal drainage apparatus. The following case report illustrates the role of this procedure in the initial workup of epiphora, as well as its value in assessing response to therapy with pseudoephedrine.

Ulcerogenic tumor syndrome of the pancreas associated with a nongastrin acid secretagogue

Among 30 patients with islet cell neoplasms or hyperplasia who exhibited marked gastric acid hypersecretion and peptic ulceration and/or diarrhea, fasting plasma gastrin concentrations were less than 150 pg/ml in 11 patients, whereas the remaining 19 patients had hypergastrinemia. Plasma extracts from seven of these 11 patients were assayed for acid secretagogue activity in rats. All seven plasma extracts had secretagogue activity that was not found in the plasma extracts of ten patients with ordinary duodenal ulcer disease. Each of the tumor or pancreatic tissue extracts obtained from nine patients exhibited secretagogue activity in rats even though tissue gastrin content was 101.9 pmol (213.8 ng).g-1 or less. The secretagogue activity of the tumor extracts was confirmed in conscious gastric fistula dogs. The tumors' secretagogue activity, in contrast to gastrin, was destroyed by trypsin. It was eluted between porcine motilin and human gastrin I from a Sephadex G-50 (Pharmacia LKB Biotechnology, Inc., Piscataway, NJ) superfine column and was not retained by CM-cellulose, at pH 8.5. Its retention time during reverse phase HPLC on a C18 column also differed from those of G17 and G34. Thus, this secretagogue activity appeared mediated by a small, acidic peptide with a molecular size of about 2000 to 3000 daltons. The present study indicates that plasma and tumor extracts of these 11 patients contain a gastric acid secretagogue activity mediated by a nongastrin peptide. We suggest that what may be a distinct clinical entity associated with endocrine neoplasms of the pancreas should be considered in the face of excessive acid hypersecretion without fasting hypergastrinemia.

Ventilation/perfusion mismatch caused by positive pressure ventilatory support

In a patient with lobar atelectasis who was on positive pressure ventilatory support, ventilation and perfusion images showed absent ventilation and normal perfusion (reverse mismatch) in the region of the atelectasis and normal ventilation and decreased perfusion (true mismatch) not caused by pulmonary embolism in another lung zone. We report this case to emphasize that the lung scan findings in patients on positive pressure ventilatory support be carefully interpreted for the diagnosis of pulmonary emboli.

Effect of patient position on interpretation of lung images complicated by chest radiograph opacities

Lung images in which perfusion defects correspond to chest radiograph (CXR) opacities in size and location are generally classified as having an intermediate probability for pulmonary embolism, while those studies in which the perfusion defects are considerably smaller than the CXR opacities are classified as having a low probability for pulmonary embolism. A case is presented in which, by imaging a patient in both the erect and supine positions, the authors were able to change the interpretation of the study from intermediate probability (perfusion defect = CXR opacity) to low probability (perfusion defect less than CXR opacity).

Use of a rapid differential stain for identifying Pneumocystis carinii in bronchoalveolar lavage fluid. Diagnostic efficacy in patients with AIDS

Identification of Pneumocystis carinii involves silver stains which require several hours for processing. Diff Quik, a differential stain similar to Wright-Giemsa, requires less than 1 min and reproducibly stains trophozoites and intracystic bodies of P carinii. To determine the utility of DQ for rapid detection of P carinii in BAL fluid, we reviewed DQ-stained slides of 50 BAL samples from 36 patients seropositive for HIV+ who had undergone bronchoscopy with BAL for evaluation of interstitial pulmonary infiltrates. A comparison group of immunocompromised patients with P carinii pneumonia also were reviewed. For HIV+ samples, sensitivity of DQ was 93 and 100 percent for cytopathologists and 75 and 89 percent for pulmonologists. Specificity was 95 percent for each cytopathologist and 100 percent for pulmonologists. For non-HIV+ patients, sensitivity ranged from 22 to 55 percent. Thus, DQ may be useful as a rapid, reliable method to identify P carinii in BAL fluid from HIV+ patients.

Detection of abnormalities in febrile AIDS patients with In-111-labeled leukocyte and Ga-67 scintigraphy

Thirty-six patients with acquired immunodeficiency syndrome (AIDS), who were febrile but without localizing signs, underwent indium-111 leukocyte scintigraphy 24 hours after injection of labeled white blood cells (WBCs) and were restudied 48 hours after injection of gallium-67 citrate. Fifty-six abnormalities were identified as possible sources of the fever; 27 were confirmed with biopsy. Of these 27, 15 were identified only on In-111 WBC scans (including colitis, sinusitis, and focal bacterial pneumonia); six, only on Ga-67 scans (predominantly Pneumocystis carinii pneumonia and lymphadenopathy); and six, on both studies (predominantly pulmonary lesions). In-111 WBC scanning revealed 21 of 27 abnormalities (78%) and gallium scanning, 12 of 27 (44%). If only one scintigraphic study has been performed, particularly with Ga-67, a significant number of lesions would not have been detected. The authors believe radionuclide evaluation of the febrile AIDS patient without localizing signs should begin with In-111 WBC scintigraphy. Gallium scanning may be used depending on results of In-111 WBC scans or if there is a high index of suspicion for P carinii pneumonia.

Buserelin in a superovulatory regimen for Holstein cows. I. Pituitary and ovarian hormone response in an experimental herd

Two experiments were conducted with frequent blood sampling in standard superovulatory regimens using follicle stimulating hormone (FSH) and prostaglandin F(2) alpha (PGF) to study the effects of the gonadotropin releasing hormone analog, Buserelin, on changes in FSH, luteinizing hormone (LH), progesterone (P(4)) and estradiol (E(2)). In Experiment I, Buserelin (20 mug) was administered to a total of 28 dry Holsteins. One group was treated with Buserelin 36 and 60 h after PGF administration, a second group was treated 60 h after PGF, and a third group served as the controls. In Experiment II, 30 dry Holsteins received Buserelin (10 mug). One group was treated 48 h after PGF, a second group at 54 h after PGF, a third group 24 h after estrus was first observed and a fourth group was a control. The general pattern of a decrease in P(4) following PGF, an increase in E(2), the onset of estrus, an LH peak, and finally, an increase in P(4) in superovulated cows was observed. Buserelin consistently produced a sharp LH peak at 36 h when given 36 h after PGF. At later intervals, it produced either a major or minor peak depending upon whether a spontaneous LH peak had already occurred. There was too much individual cow variation in the interval from PGF to a spontaneous LH peak to consistently induce a uniform LH peak, except when Buserelin was given 36 h after PGF, which may be early for normal oocyte maturation. There was no treatment effect on FSH, and embryo recovery rate was unaffected by treatment (P>0.05).

In vitro capacitation and fertilizing ability of ejaculated rabbit sperm treated with lysophosphatidylcholine

Four experiments were replicated 1) to establish dose-response relationships between lysophosphatidylcholine (LPC), sperm motility, and the acrosome reaction (AR), 2) to evaluate the influence of rabbit serum (RS) on these endpoints, 3) to compare buck differences in induction of the AR, and 4) to examine fertilizing ability in vitro of sperm tested under the first three objectives. Semen was collected from Dutch-belted rabbits, washed once by centrifugation, resuspended, and preincubated for 2 or 4 hr in a chemically defined medium (DM), DM plus 20% RS, or BSA-free DM plus 20% RS at 37 degrees C. At the end of preincubation LPC was added to the preincubated sperm at concentrations of from 0 to 100 micrograms/ml. Sperm were examined .5-4 hr later for AR and sperm motility. For in vitro fertilization, sperm and ova were coincubated in DM up to 24 hr after insemination and in a more complex medium for another 24 hr. Addition of LPC to 4-hr-preincubated sperm was more effective for inducing the AR than addition to 2-hr-preincubated sperm. A significant increase (P less than .05) in the AR occurred in 15 and 30 min following exposure to 100 and 80 micrograms of LPC per ml, respectively, but the higher concentration of LPC decreased sperm motility. Addition of 20% RS to DM with or without BSA surprisingly inhibited the AR but maintained sperm motility, as expected. Bucks differed (P less than .05) in the initial percentage and the induced percentage of AR sperm. For the AR the optimal concentration of LPC per ml was 80 micrograms, but for in vitro fertilization 60 micrograms tended to be superior.

The effect of genetic counseling on performance of prenatal cytogenetic diagnosis

Currently the number of pregnant women who have indications for, but do not receive, prenatal cytogenetic diagnosis is increasing. The purpose of this study was to review the prenatal cytogenetic services and to analyze the effect of genetic counseling on performance of the prenatal cytogenetic test. From January 1987 to July 1988, there were 2,796 deliveries at Severance Hospital, Yonsei Medical Center, of which 126 patients had indications for prenatal cytogenetic diagnosis. Chromosomal abnormalities were found in 5 patients (1, monosomy X; 1, trisomy 18; and 3, trisomy 21). Four patients were found in the group who had indications for prenatal cytogenetic diagnosis while only one was found in the group who did not (p less than 0.01). The most common indication for prenatal cytogenetic diagnosis was advanced maternal age (59%). The prenatal test rate was highest in patients whose indications were a previous child with chromosomal abnormality (100%) and parental translocation carrier (100%). Most (89%) of the patients were tested by amniocentesis between the 16th and 20th week of gestation. The two most common reasons for patients not receiving a prenatal cytogenetic diagnosis were late registration (41%) and absence of genetic counseling (34%).

Outbreaks of Pneumocystis carinii pneumonia in colonies of immunodeficient mice

Outbreaks of Pneumocystis carinii pneumonia occurred in colonies of nu/nu and scid/scid mice at four different institutions. The disease, which was characterized by chronic wasting and respiratory insufficiency, was more severe in older mice and in animals housed in cages with special protective tops. Histopathologic features included alveolar filling with the typical foamy honeycomb material and a mild, nonspecific host inflammatory response. Immunofluorescence and immunoblotting studies suggested the P. carinii isolate was of mouse rather than of rat or human origin, and the outbreaks could be related to each other by common vendor or source of breeding animals. Once P. carinii became established in a mouse colony, the organism tended to persist for long periods of time. The principal control measure was depopulation of the colony, although limited experience with the administration of trimethoprim-sulfamethoxazole was encouraging. Thus, outbreaks of pneumocystosis are a serious problem among colonies of immunodeficient mice, with important implications for the use of these animals in biomedical research. Data obtained by studying these outbreaks should enhance understanding of the pathogenesis of P. carinii pneumonia and be helpful in formulating improved methods of detection and control.

A case of recurrent infantile polycystic kidney associated with hydrops fetalis

Nonimmune hydrops fetalis is becoming a predominant form of fetal hydrops due to the declining incidence of immune hydrops fetalis triggered by Rh isoimmunization. Infantile polycystic kidney appeared to be related to hydrops fetalis whether it is causal or merely coincidental and may represent another entry to differential diagnoses. Infantile polycystic kidney was diagnosed by an elevated maternal serum alpha-fetoprotein (AFP) value coupled with an ultrasonographic abnormality scanned as a multicystic mass with ascites in the fetal abdomen antenatally. This study presents a case of infantile polycystic kidney that resulted in a stillborn baby with hydrops fetalis and extensive placental calcification; it was the first case in Korea in which nonimmune hydrops fetalis was associated with infantile polycystic kidney in consecutive siblings by autosomal recessive inheritance in one family. In addition, this paper comprehensively reviews the incidence, etiology, prenatal diagnosis and proper management of nonimmune hydrops fetalis.

Genetic organization and nucleotide sequence of the stability locus of IncFII plasmid NR1

The stability (stb) locus of IncFII plasmid NR1 was mapped to a 1700 base-pair NaeI-TaqI restriction fragment. A series of unstable plasmids that contained insertion, deletion, and point mutations that inactivated the stability function was isolated. The unstable point mutants examined were all stabilized (complemented) in trans by a copy of the wild-type stb locus, suggesting that the mutations had inactivated diffusible gene products. The nucleotide sequence of the stb locus contained two tandem open reading frames, designated stbA and stbB, that encoded essential trans-acting protein products with predicted sizes of 36,000 Mr and 13,000 Mr, respectively. A third open reading frame, stbC, that could encode a peptide of 8000 Mr was contained within stbB in the complementary DNA strand. Plasmid-encoded proteins of 36,000 Mr and 13,000 Mr were identified in minicell experiments as the products of stbA and stbB, respectively. Unstable deletion mutants that retained the promoter proximal region of the stb locus upstream from stbA but had deleted both stbA and stbB were stabilized in trans by plasmids that could supply StbA and StbB. In contrast, deletion mutants that had lost the stbAB promoter region were not complemented in trans, indicating that this region contained an essential cis-acting site (or sites). Unlike some other loci that mediate stable plasmid inheritance, cloned copies of the wild-type stb locus of NR1 did not exert strong incompatibility (i.e. trans destabilization) against other stb+ derivatives of plasmid NR1 present in the same cell.

Cationic antitrypanosomal and other antimicrobial agents in the therapy of experimental Pneumocystis carinii pneumonia

Cationic compounds used in the treatment of veterinary African trypanosomiasis have structural properties similar to those of pentamidine, which has been used in the therapy of human trypanosomiasis and infection with Pneumocystis carinii. We have compared the activities of these drugs and other antimicrobial agents in an immunosuppressed rat model of P. carinii pneumonia. Diminazene, imidocarb, amicarbalide, quinapyramine, and isometamidium showed efficacy greater than or equal to that of pentamidine in the therapy of P. carinii infection, whereas ethidium and methylglyoxal bis(guanylhydrazone) were only slightly active against the organism. Diminazene and pentamidine also exhibited comparable efficacy in P. carinii prophylaxis, alpha-Difluoromethylornithine (DFMO), a polyamine inhibitor, was ineffective therapy when used alone and did not improve the effectiveness of pentamidine or diminazene. Quinine, quinidine, quinacrine, chlorpromazine, spiramycin, Pentostam, Astiban, dehydroemetine, ampicillin, gentamicin, chloramphenicol, and spectinomycin also showed little or no activity against the organism. Thus, in this model anti-P. carinii activity appears to be a common property of veterinary cationic trypanocidal compounds. This should be important in studying structure-activity relationships and in developing new drugs for the treatment of P. carinii infection in humans.

Pneumocystis carinii infection of the small intestine in a patient with acquired immune deficiency syndrome

The authors describe a patient with acquired immune deficiency syndrome (AIDS) who presented with an acute abdomen. A plaque-like tumor of the small intestine was resected and found to consist of masses of Pneumocystis carinii organisms. The organisms also exhibited a perivascular and intravascular distribution. Identical changes were found in regional lymph nodes. In addition to silver stains and electron microscopy, an immunohistochemical method for the demonstration of P. carinii was employed. The technique may have advantages over silver staining, as it identifies trophozoites in addition to cysts. A review of the literature concerning extrapulmonary pneumocystosis indicates that affected patients nearly always have concurrent pulmonary infection. The pattern of organ involvement and the finding of perivascular and intravascular organisms are consistent with lymphatic or hematogenous dissemination from the pulmonary focus. Pulmonary pneumocystosis was not documented in the patient described herein, although there were radiographic densities in one pulmonary lobe.

Marrow granulomas in coal workers' pneumoconiosis. A histologic study with elemental analysis

The differential diagnosis of bone marrow granulomas is lengthy but has not previously included coal workers' pneumoconiosis. This report describes the first case in which noncaseating epithelioid granulomas containing anthracotic pigment and birefringent silica containing crystals were discovered in the marrow of a patient with progressive massive fibrosis of coal workers' pneumoconiosis. The silicotic nature of the crystals was confirmed using energy dispersive x-ray microanalysis. There was no evidence of a mycobacterial, fungal, or other etiology for the granulomas. This case demonstrates that coal workers' pneumoconiosis should be added to the differential diagnosis of bone marrow granulomas and that marrow examination may be a source of tissue for documentation of specific occupational exposures.

Inhibitors of folic acid synthesis in the treatment of experimental Pneumocystis carinii pneumonia

Inhibitors of folic acid synthesis were compared alone and in different combinations in the therapy of pneumocystosis in immunosuppressed rats. Sulfonamides (sulfamethoxazole, sulfadiazine, and sulfadoxine) and sulfones (dapsone) used alone were very active against Pneumocystis carinii, as judged by histologic examination of the lungs and by organism quantitation. Improved efficacy could not be demonstrated by the addition of an inhibitor of dihydrofolate reductase to the regimen. Dihydrofolate reductase inhibitors (trimethoprim, diaveridine, and pyrimethamine) used alone were ineffective against P. carinii. All drugs were well tolerated except pyrimethamine, which caused bone marrow depression; folinic acid ameliorated this adverse reaction but did not interfere with P. carinii treatment. These data have potential clinical implications but need to be interpreted with caution and in light of other systems of P. carinii drug evaluation.

Comparison of histologic and quantitative techniques in evaluation of therapy for experimental Pneumocystis carinii pneumonia

Pneumocystis carinii pneumonia was induced in rats by the administration of corticosteroids, and histologic and quantitative techniques were compared in the evaluation of the severity of the disease and response to therapy. A highly significant correlation was found between the histologic score of the extent of alveolar involvement (the standard method of assessment) and the number of P. carinii cysts and nuclei in lung homogenates, lung weight, and lung weight/body weight ratio. Clear differences were noted between rats which responded well and rats which responded poorly to therapy by all techniques. Quantitation of P. carinii cysts and nuclei revealed a 10(4)-fold reduction in organism burden with successful treatment. Thus, these techniques should be helpful in the development of testing of new antimicrobial agents in the rat model of pneumocystosis.

The pathogenesis of experimental pulmonary histoplasmosis. Correlative studies of histopathology, bronchoalveolar lavage, and respiratory function

A murine model of acute pulmonary histoplasmosis was employed to study the pathogenesis of the disease process by means of histopathology, bronchoalveolar lavage, and respiratory function tests. These studies were performed on C57BL/6 mice from 8 h to 8 wk after intranasal inoculation of 10(5) yeast forms of Histoplasma capsulatum and on age-matched control animals that received saline only. At Week 1, the histopathology was characterized by subacute inflammation consisting of polymorphonuclear leukocytes (PMN), lymphocytes, and macrophages that infiltrated the interstitium around small bronchioles and adjacent alveoli. At Weeks 2 and 4, the infiltrates were comprised predominantly of lymphocytes and macrophages; noncaseating granulomas were present at Week 2. Aggregates of lymphoid cells were prominent along the bronchial tree and in perivascular distribution. Those in close contact with bronchiolar epithelium resembled hyperplastic bronchus associated lymphoid tissue. Quantitative studies of cells in the BAL fluid revealed a large influx of PMN at Week 1 with return to normal range by Week 2. At this time there was a significant (p less than 0.02) increase in lymphocytes that persisted through Week 8, although histopathologic changes were minimal in lung at this time. A significant decrease in the DLCO/TLC at Week 2 in association with a normal vital capacity indicated impairment of respiratory function secondary to the alveolitis induced by H. capsulatum infection rather than a reduction of lung volume. This model offers promise for additional correlative studies of lymphocyte subsets in lung tissue and alveolar spaces as well as of the functions subserved by these respective populations.

Human leukocyte antigen (HLA) in Korean patients with autoimmune thyroid diseases

In previous studies, there has been evidence of different allelic associations with a particular disease among various ethnic groups. The present study was done to investigate the associations between HLA and autoimmune thyroid diseases in the Korean. We found no association between Graves’ disease and HLA-B8 or -B35. However, increased frequencies of HLA-A11 and -DRw8, and the decreased frequencies of HLA-A10 and B12 were found in patients with Graves’ disease. In the cases of Hashimoto’s disease, the frequencies of HLA-A2 and -DRw8 were found to be significantly increased and the frequency of HLA-DRw6y decreased. These data indicate that the association between autoimmune thyroid disease and HLA in the Korean would appear to be different from that in most other racial groups, including Caucasians, Japanese and Chinese.

The role of propranolol in the preoperative preparation of patients with Graves' disease

From March 1980 to August 1982, 108 patients with Graves' disease participated in a prospective study at Yonsei University College of Medicine. Preoperatively, 22 patients were prepared with propranolol alone (group 1) and 86 with propranolol and propylthiouracil (PTU) (group 2). The duration of preparation averaged 11.5 days for group 1 and 10.8 days for group 2. Bilateral subtotal thyroidectomy was performed, leaving 4 to 6 grams at both upper poles. No significant difference was noted in the average weight of the removed gland or the amount of blood loss between both groups. During the operation, the pulse rate of group 1 was significantly faster than that of group 2 but evened out by the day of discharge. The incidence of high fever during and immediately after operation was 27.3 per cent in group 1 which is greater than the 17.4 per cent in group 2. In group 1, the incidence of postoperative transient hypocalcemia was 27.3 per cent, transient or prolonged hypothyroidism was 13.6 per cent and recurrence of thyrotoxicosis was 4.5 per cent. In group 2, the values were 22.1, 18.6 and 4.7 per cent, respectively. High fever developed in one patient from group 1 during operation and this patient died on the third day postoperatively. From the results of our study, it appears to be more beneficial to administer both propranolol and PTU as preoperative medication to patients with Graves' disease prior to undergoing operation.

Variation of differential cell counts of bronchoalveolar lavage fluid

Bronchoalveolar lavage (BAL) is a common research and clinical tool to retrieve cells from the lower respiratory tract. Differential cell counts of the nucleated cells retrieved by BAL provide important diagnostic and prognostic information. There is much variation between laboratories in the reported normal percentages of lymphocytes and macrophages of cells retrieved by BAL. We compared three methods of identifying cells in the BAL fluid: a modified Wright-Giemsa (WG) stain, a nonspecific esterase stain, and a monoclonal marker for T lymphocytes. There was good agreement between the percentage of macrophages identified by WG and nonspecific esterase and the percentage of lymphocytes determined by WG stain and monoclonal marker. Intrasubject and intersubject agreement of the differential cell counts determined by the WG stain was good. We concluded that cells from BAL fluid can be analyzed using the WG stain alone.

Takayasu's arteritis associated with interstitial lung disease and glomerulonephritis

Takayasu's arteritis is a vasculitis characterized by inflammation and obliteration of large- and medium-sized arteries and has not been previously associated with interstitial pulmonary fibrosis. A patient with Takayasu's arteritis was shown to have interstitial pulmonary fibrosis and mesangial glomerulonephritis, suggesting a common antigenic stimulus that resulted in tissue injury.

Failure of ketoconazole in an immunosuppressed patient with pulmonary blastomycosis

A renal transplant recipient presented with pulmonary blastomycosis. Because of recent data suggesting a role for ketoconazole in the treatment of blastomycosis and concern for preserving her functioning renal transplant, she was started on therapy with ketoconazole, 400 mg daily. After four months of continuous therapy, she developed skin and laryngeal involvement requiring emergency tracheostomy; subsequent therapy with amphotericin B resulted in resolution of her disease. This is an example of life-threatening progression of blastomycosis in an immunosuppressed patient during ketoconazole therapy.

Leber's optic atrophy with myopia masquerading as glaucoma: case report

In recent years there has been much discussion in the literature regarding the proper approach to the patient who presents with apparent "low tension" glaucoma. In addition to a complete workup and proper management of such a patient, careful consideration must be given to the differential diagnosis of clinical conditions presenting with optic disc cupping and visual field changes. We present an interesting clinical situation in which a patient with severe myopia and Leber's optic atrophy was referred for surgery for treatment of apparent progressive "low tension" glaucoma.

Small cell carcinoma of urinary bladder. Ultrastructural study

Two cases of small cell carcinoma of the urinary bladder are presented. On gross examination they were found to be polypoid and shared light microscopic features of oat cell carcinoma of the lung. Ultrastructurally, however, they did not reveal features of neuroendocrine cells containing neurosecretory granules. In regard to histogenesis, they appear to arise from undifferentiated cells present in the transitional epithelium.