Recurrent diffuse osteomyelitis involving the mandible

This report describes a case of osteomyelitis that did not respond to routine hyperbaric oxygen, surgical debridement, and intravenous antibiotics. The multiple sites of the osteomyelitis, the presence of skin lesions, and the unusual organism (Corynebacterium group JK, L form) that was isolated indicated that the patient might have an immunodeficiency, but none could be identified.

Sjögren's syndrome presenting with hypereosinophilia, lymphopenia and circulating immune complexes

Although mild peripheral eosinophilia is a common finding in Sjögren's syndrome (SS), severe eosinophilia with a clinical picture simulating hypereosinophilic syndrome is extremely rare. We report a 24 year old male with SS presenting with swelling of the parotid glands, redness and irritation of the eyes, polyarthralgias and polyarthritis, weight loss, exertional dyspnea, malaise, erythematous and urticarial skin lesions and enlarged lymph nodes. Laboratory tests showed hypereosinophilia (34%, total 3800/mm3), lymphopenia (2%, total 220/mm3), a positive RA factor (1:2560) and decreased C3 and C4. Biopsy of an enlarged submaxillary gland was consistent with SS. A Schirmer test showed decreased tear production. Salivary glands showed a marked decrease in uptake of radioactive (Tc99) dye. Circulating immune complexes (CIC) were markedly elevated by both C1q binding and Raji cell assays. T-cell subsets showed OKT3 = 63%, OKT4 = 32% and OKT8 = 16%. "Histamine trap" in vivo test for CIC revealed fluorescence in upper dermal blood vessels with IgM, C1q, C3 and fibrin. Biopsies of the liver, bone marrow and skin revealed eosinophilic infiltration. A notable response to therapy with high doses of corticosteroids was seen with recurrence of symptoms and laboratory abnormalities after the therapy was stopped. In conclusion, we present a case of SS which is remarkable for the age and sex of the patient, extreme hypereosinophilia, marked lymphopenia, and CIC.

The feasibility of barcode-based dispensing quality assurance programs

A study was conducted to evaluate the feasibility of using barcodes in an outpatient pharmacy quality assurance program. In the first step of this study, adhesive labels containing a barcode representation of the National Drug Code (NDC) identification for the hospital's formulary medications were printed for each stock bottle or drug package used in dispensing. When an outpatient prescription was presented to the pharmacist, a label containing a barcode representation of the NDC identification for the prescribed medication was generated on-line and attached to the back of the prescription form. After the prescription item was filled by the pharmacist, an automated check was performed with a scanning wand by comparing the barcode on the prescription with the previously generated barcode on the stock bottle or drug packaging. A match indicated that the correct medication had been dispensed. Elaborations on this basic automated system for a barcode-based dispensing quality assurance program are suggested.

Diagnosis of Polistes wasp hypersensitivity

Patients referred from the Houston, Texas, metropolitan area were evaluated for allergic reactions to insect stings. Forty-eight persons reported at least one systemic reaction caused by a Polistes paper-nest wasp sting. Honey bees, imported fire ants, and other types of Hymenoptera were identified in that order by 19 other subjects with systemic allergic reactions. Life-threatening airway obstruction and/or hypotension were noted by most of our patients. Wasp venom skin testing was positive in 65% of subjects reporting sensitivity to this insect. Skin testing was correlated quantitatively with basophil histamine release, and qualitatively with RAST assays using Polistes wasp venom. Venoms from common species of Polistes were highly cross-reactive as shown by RAST and basophil histamine release. Patients having a positive history and laboratory response (by skin testing, histamine release, or RAST) to Polistes wasp venom also were positive to bee venom about 20% of the time and to another vespid (hornet or yellow jacket) over 50% of the time.

Genetic variation among dengue 2 viruses of different geographic origin

Genetic variation in dengue 2 isolates from various geographic areas was examined by oligonucleotide fingerprinting of the 40 S genome RNA. Oligonucleotide maps of geographically isolated and epidemiologically unrelated viruses were very distinct. Direct comparison of the oligonucleotide map of the dengue 2 prototype New Guinea 2 virus, isolated in 1944, with the fingerprints of more recent isolates from the South Pacific indicated that the genome of dengue 2 virus had undergone extensive change although the viruses are serologically indistinguishable. The oligonucleotide map of an isolate from a recent case in Jamaica and a mosquito isolate from Upper Volta, Africa, were recognized to be almost identical, suggesting that virus may have been introduced into the Caribbean from West Africa. Likewise, the fingerprints of isolates from Puerto Rico and the South Pacific shared 80 to 95% of their large oligonucleotides, suggesting that the virus involved in these epidemics may have spread throughout Tahiti, American Samoa, Fiji, and to Puerto Rico in the Caribbean or vice versa. On the basis of these studies, five genetic variants or topotypes of dengue 2 virus have been established: (1) Puerto Rico-South Pacific, (2) Burma-Thailand, (3) the Seychelles, (4) the Philippines, and (5) Jamaica-West Africa. Oligonucleotide fingerprinting offers a highly sensitive and reproducible technical approach to the investigation of dengue 2 virus intratypic variation and possibly to the understanding of the biological variation associated with dengue fever and hemorrhagic disease.

Comparison of the allergenicity and antigenicity of Polistes venom and other vespid venoms

The crossantigenicity of Polistes venom with other vespid venoms was examined with rabbit and human antisera. Venom preparations from various Polistes species were obtained by electrical stimulation of individual insects and venom sac dissection. Rabbit antibodies were raised to the venom (P. apachus) and venom sac extract (P. exclamans). Human antisera were obtained from patients allergic to Polistes and other vespid venoms. The venom appeared to be more potent than the venom sac preparations in reactions with rabbit IgG and human IgE antibodies. Among the Polistes species, P. exclamans, P. instablis, and P. apachus venoms showed several lines of precipitation with rabbit antisera, and P. annularis and P. fuscatus venoms only one line, suggesting quantitative or qualitative antigenic differences. In RAST analysis, most sera reacted equally to all Polistes species but occasional exceptions were noted, again suggesting differences in venom allergens. P. exclamans-coupled discs gave the most consistent results. In gel diffusion experiments, there was no crossreactivity between Polistes and yellow jacket venoms and only limited crossreactivity between Polistes and hornet venoms. Patients sensitive to Polistes venom showed varying degrees of reactivity to yellow jacket and hornet venoms in RAST analysis. Patients sensitive to other vespid venoms also showed varying degrees os sensitivity to Polistes venom. Polistes venom appears to contain a genus-unique antigen (allergen). In addition, there appear to be some crossreacting antigens in Polistes and other vespid venoms but to a much lesser degree than found previously in the analysis of the relationship of yellow jacket and hornet venoms.

Dissociation between cutaneous basophil hypersensitivity and basophil sensitization

We investigated the antigen-specific sensitization of basophils in the peripheral circulation of guinea pigs using an in vitro histamine release assay. Animals were primed for cutaneous basophil hypersensitivity (CBH) by intradermal injection of either keyhole limpet hemocyanin (KLH) or ovalbumin (OA) in saline. Basophils isolated from these animals 7 days after sensitization did not release histamine to the specific antigen in vitro. On day 9, however, basophils did release histamine when challenged with the antigen. These results were in contrast to 24-hr skin tests that showed a typical CBH profile both on day 7 and day 9. When animals were immunized via the footpad by emulsification of antigen in incomplete Freund's adjuvant, basophil sensitization (i.e., histamine release) either occurred earlier (day 7, KLH) or at lower antigen concentrations (OA). Thus, dissociation of in vivo CBH and in vitro basophil sensitization was demonstrated. The lack of correlation was only seen early after immunization and depended on the route of immunization used. An additional finding was a transient blood basophilia that also was dependent on the route of immunization, the antigen used, and the time post-sensitization. Our results are consistent with the hypothesis that at early times post-immunization, CBH is mediated by T cells and not via homocytotropic antibodies, but that at later times such antibodies may also play a role in the elicitation of CBH reactions.

Dissociation between cutaneous basophil hypersensitivity and basophil sensitization

We investigated the antigen-specific sensitization of basophils in the peripheral circulation of guinea pigs using an in vitro histamine release assay. Animals were primed for cutaneous basophil hypersensitivity (CBH) by intradermal injection of either keyhole limpet hemocyanin (KLH) or ovalbumin (OA) in saline. Basophils isolated from these animals 7 days after sensitization did not release histamine to the specific antigen in vitro. On day 9, however, basophils did release histamine when challenged with the antigen. These results were in contrast to 24-hr skin tests that showed a typical CBH profile both on day 7 and day 9. When animals were immunized via the footpad by emulsification of antigen in incomplete Freund's adjuvant, basophil sensitization (i.e., histamine release) either occurred earlier (day 7, KLH) or at lower antigen concentrations (OA). Thus, dissociation of in vivo CBH and in vitro basophil sensitization was demonstrated. The lack of correlation was only seen early after immunization and depended on the route of immunization used. An additional finding was a transient blood basophilia that also was dependent on the route of immunization, the antigen used, and the time post-sensitization. Our results are consistent with the hypothesis that at early times post-immunization, CBH is mediated by T cells and not via homocytotropic antibodies, but that at later times such antibodies may also play a role in the elicitation of CBH reactions.

Enzyme-like immunosorbent assay (ELISA) for immunoglobulin G antibodies against insect venoms

IgG "blocking" antibodies were measured in patients receiving insect venom immunotherapy. The enzyme-linked immunosorbent assay (ELISA) described herein was found to be sensitive and reproducible. Results with ELISA correlated well with values obtained with a radioimmunoassay and with inhibition of the release of histamine from sensitive basophils. Also, specific antibody titers against phospholipase A and whole bee venom were correlated. Serial determinations of venom-specific IgG antibodies were made in 17 patients receiving Polistes wasp or bee venom immunotherapy. The majority of patients showed a rise in IgG antibodies, which peaked after administration of approximately 500 micrograms of venom. Only one out of 13 of these venom-treated patients had allergic symptoms after an insect sting while on maintenance therapy.

Enhancement of basophil chemotaxis in vitro by virus-induced interferon

It is well established that viral infections may precipitate or worsen attacks of bronchial asthma. Furthermore, in symptomatic atopic subjects, the local accumulation of basophils and the production of a basophil chemotactic factor have been reported. We have investigated the effect of cell-free supernates from viral stimulated cultures of human mononuclear cells on the in vitro migration of human basophils. Our results show the presence of a factor in these culture supernates that enhances the migration of basophils toward two separate chemoattractants, a peptide from C5 and a lymphokine. The enhancing activity, while affecting basophil migration, did not change the response of monocytes. The enhancing activity resembled viral-induced interferon when (a) pH 2 stability, (b) heat resistance, (c) trypsin sensitivity, and (d) species-specificity were compared. Finally, the enhancing activity for basophil chemotaxis and the interferon titer were highly correlated in preparations with a 10(4)-fold difference in interferon specific activity. Our studies show that viral-induced interferon can augment the in vitro chemotactic response of basophils. Because mediators present in basophils may be involved in the pathogenesis of immediate hypersensitivity, the modulation of basophil movement by interferon suggests a possible mechanism for the association between viral infections and atopic disorders.

Antigen-induced histamine release from guinea pig basophils

Guinea pig blood was found to contain an average of 106 +/- 21 ng/ml of histamine. Of this total, approximately 85-90% was of platelet origin and the rest from basophils. Basophils contain about 0.72 pg of histamine/cell. Concanavalin A (1-5 microgram/ml) induced the release of approximately 65% of the basophilic histamine. When basophils were isolated from animals sensitized to ovalbumin or keyhole limpet hemocyanin, addition of the appropriate antigen induced histamine release at concentrations of 0.01 microgram/ml or lower. Individual animals were studied over time by repetitive bleeding. The circulating basophils remained sensitized for at least 17 weeks postsensitization. However, release did not occur if animals had been sensitized less than 7 days earlier. This assay facilitates the investigation of basophil sensitization since animals can be studied on several occasions following immunization. The mechanisms, timing and role of basophil sensitization in various types of immune and hypersensitivity reactions can now be evaluated.

Local heat urticaria/angioedema: evidence for histamine release without complement activation

A 42-yr-old white woman reported onset in 1976 of local pruritus, burning, erythema, and edema within minutes after exposure in heat. With more extensive exposure, she occasionally had transient headaches and nausea. In order to investigate the etiology of this condition, her forearm was exposed to water at 44 degree C for 4 min. Within a few minutes, a lesion identical to her spontaneously induced ones developed only at the area exposed to heat. Samples of venous blood from this extremity demonstrated a transient rise in plasma histamine levels without any significant change in serum hemolytic complement activity or in C3, C4, or factor B. These findings suggest that this rare syndrome involves local activation of mediator release from mast cells, without participation of the complement system.

Anaphylactic reactions following infusion of factor VIII in a patient with classic hemophilia

A 28 year old white man with hemophilia A had, for several years, been successfully maintained on a home care program utilizing self-administration of factor VIII concentrates, but one such infusion resulted in severe anaphylaxis. An immunoglobulin E (IgE)-mediated hypersensitivity response was demonstrated by (1) the release of histamine from the patient's basophils in vitro upon challenge with several different lots of factor VIII concentrate; (2) immediate cutaneous response to commercial factor VIII, factor IX and cryoprecipitate; and (3) measurement of IgE antibodies against a commercial factor VIII preparation. A subsequent life-threatening hemorrhage required cautious infusion of another commercial lot of factor VIII concentrate. Despite pretreatment with antiallergic drugs and attempted desensitization, a moderately severe anaphylactic reaction was observed.

A comparison of New World alphaviruses in the western equine encephalomyelitis complex by immunochemical and oligonucleotide fingerprint techniques

We have examined the molecular basis for the observed antigenic differences between isolates of western equine encephalomyelitis (WEE) virus and those of a serologically related alphavirus from the eastern United States designated Highlands J (HJ). The structural proteins of WEE virus isolates have mol. wt. of 55 x 10(3) (E1), 47 x 10(3) (E2) and 33 x 10(3) for the nucleocapsid. The E1 glycoprotein had an isoelectric point (pI) of 6.4 and induced haemagglutination-inhibiting (HI) antibody which was specific for WEE virus. The E2 glycoprotein of WEE virus had a pI of 8.4 and induced antibody which was virus specific by neutralization (PRNT) but cross-reacted with HJ virus in the radioimmune precipitation (RIP) test. Envelope glycoproteins of HJ virus isolates had mol. wt. of 58 x 10(3) (E1) and 49 x 10(3) EW) respectively. The E1 glycoprotein from HJ virus had a pI of 6.8 and induced antibody which reacted specifically in the HI, PRNT and RIP tests. Isolated E2 protein of HJ virus had a pI of 9.1 and induced antibodies which were reactive at equal titre with both WEE and HJ viruses by RIP. Two-dimensional gel electrophoresis of RNase T1 oligonucleotides of WEE virus and HJ virus genome RNase T1 oligonucleotides revealed that the primary structures of the RNAs of these two serologically related alphaviruses were very distant. The fingerprints of the oligonucleotides from 16 WEE viruses from western and central North America, Mexico and South America were similar to each other and easily distinguished from those of the eight HJ viruses isolated in the eastern United States from Massachusetts to Louisiana.

Interaction of selective alpha-adrenoceptor agonists and antagonists with human and rabbit blood platelets

1 The selectivity of alpha-adrenoceptors mediating the pro-aggregatory response of human and rabbit platelets to adrenaline and the conditions required to permit expression of an aggregatory response to partial agonists at these alpha-adrenoceptors have been studied.2 Yohimbine causes effective blockade of the pro-aggregatory responses whereas indoramin and prazosin are ineffective.3 The clonidine analogue, UK-14304, is nearly as effective as adrenaline in inducing an aggregatory response in human platelets and a pro-aggregatory response in rabbit platelets. Cross-tachyphylaxis between adrenaline and UK-14304 has been demonstrated.4 Clonidine is a weak agonist for the pro-aggregatory response of rabbit platelets and in some donors for the aggregatory response of human platelets.5 Methoxamine induces a pro-aggregatory response in human platelets which is blocked by indoramin or prazosin but not by yohimbine. No such response to methoxamine is observed in rabbit platelets.6 The divalent cation ionophore, A-23187, induces an aggregatory response to clonidine (in platelets from a non-responsive donor), phenylephrine and methoxamine in human platelets and to adrenaline, UK-14304 and clonidine in rabbit platelets. A secretory response to clonidine is also induced by A-23187 in human platelets.7 The adenylate cyclase inhibitor, SQ-22536, is ineffective in either inducing a response to the alpha-agonists or potentiating the effect of A-23187.8 The aggregatory responses to adrenaline and UK-14304 in rabbit platelets and to clonidine in human and rabbit platelets, which can be induced by A-23187, are blocked by yohimbine but not by prazosin or indoramin.9 From these studies we conclude that the pro-aggregatory responses of human and rabbit platelets to adrenaline are mediated primarily by alpha(2)-adrenoceptors. The presence of alpha(1)-adrenoceptors on human platelets is confirmed but these receptors do not appear to be present on rabbit platelets. The conditions required for expression of an aggregatory response to partial agonists at the human and rabbit platelet alpha-adrenoceptors implicate an increase in cytosolic Ca(2+) concentration as a key event in stimulus-response coupling but do not indicate such a role for depression of cyclic adenosine-3',5'-monophosphate concentration.