Fungal arthritis. A review

Fungal arthritis (FA) due to a candida infection was reviewed in English literature and described in 45 cases. The increasing use of potent antibiotics, immunosuppressives, and especially the use of artificial joints, predisposed to the infection. Weightbearing joints, particularly the knees, were most frequently affected. Symptoms were described as a warm, tender and swollen joint, and the duration of symptoms prediagnosis was described as being up to 4 years. Amphotericin B was the treatment drug of choice, and in cases of no response, supplemented with either flucytosine or ketoconazole. Local FA healed in all cases. FA in an artificial joint resulted in all cases in removal of the prostheses. Mortality in systemic fungal infections including FA was 50%.

Epileptic seizures, arthrogryposis, and migrational brain disorders: a syndrome?

INTRODUCTION

Arthrogryposis multiplex congenita (AMC) may be associated with multiple developmental defects. In some severely affected newborns with AMC, autopsy studies have suggested a common mechanism of malmigration at the spinal and cerebral levels. To our knowledge, a constellation of arthrogryposis, epileptic seizures, and brain migrational anomalies in adult patients has not previously been described in a clinical material.

MATERIAL AND METHODS

Six consecutive adult patients with arthrogryposis multiplex congenita and epileptic seizures form the basis of the present study. Five patients had joint contractures and reduced muscle volume restricted to the lower extremities, whereas one patient had predominantly upper extremity affection. They were studied with magnetic resonance imaging (MRI), EEG, EMG, a neuropsychological test battery, and chromosome analysis.

RESULTS

Four of them had clear evidence of migrational brain disorders, demonstrated by MRI, in three of them roughly corresponding to the focal epileptiform EEG activity. Five of the patients had partial seizures, whereas one only had generalized tonic-clonic seizures. The MRI findings included polymicrogyria, pachygyria, and fused schizencephaly. Four had neurogenic EMG changes, one had myopathic EMG features, and one had an unremarkable EMG pattern in affected muscles. All patients with demonstrable migrational disorders showed abnormal neuropsychological features. Three patients were mentally retarded. A chromosome abnormality in the form of a ring chromosome 18 was present in one patient.

CONCLUSION

We suggest that AMC, epileptic seizures, and migrational brain disorders may form the integral parts of a hitherto undescribed syndrome in adults. A wide-spread defect in neuronal migration along the entire neural axis may be the underlying mechanism of the cerebral and the peripheral symptoms.

Increase of endo-peptidases and exo-peptidases in thyroid-tumors

Production of proteolytic enzymes is important for the invasive properties of malignant tumours. In this series of 43 cases of various non-neoplastic and neoplastic thyroid lesions, the activity of dipeptidyl peptidase I and dipeptidyl peptidase IV was increased in papillary carcinomas. In addition, cathepsin B and cathepsin L were markedly elevated in 2 of 3 follicular carcinomas, and tryptase, which is a marker of mast cells, was also significantly elevated in follicular carcinomas. Our results indicate that proteolytic proteins are important in thyroid carcinomas, and in addition there seem to be some differences between papillary and follicular tumours. Larger studies are needed to confirm these findings.

The effect of phenobarbital on cerebral blood flow in newborn infants with foetal distress

The effect of phenobarbital on cerebral blood flow (CBF) was investigated by the intravenous Xenon133 clearance technique in seven term newborn infants with signs of mild to moderate hypoxic ischaemic encephalopathy, all on sustained spontaneous ventilation. Phenobarbital treatment had no significant effect on CBF 60 min after loading dosage (20 mg/kg i.v.). Likewise, no significant change in mean arterial blood pressure, heart rate or transcutaneous gas tensions was observed. Though slight changes in CBF of short duration cannot be excluded, conventional dosage of phenobarbital to term newborn infants with foetal distress apparently imposes no risk of cerebrovascular damage.

[Septic arthritis]

Septic arthritis (SA) is reviewed in the English literature with reference to registration of localisation of the infected joints, the bacteriological cause, predisposing factors, clinical information and laboratory data related to SA. Seventy-eight publications were available concerning 975 patients with 1086 infected joints caused by 1032 bacteria. Large joints such as the knee and hip were most frequently, however, infected, in recent years, SA in small axial joints has been reported with increased frequency. Gram-positive cocci and especially Staphylococcus aureus are most frequently the cause of infection. High temperatures, elevated sedimentation rate and leucocytosis are often noticed in SA, as is a warm, tender, swollen joint with effusion and painful movements. Investigation of the aspirated fluid from the joint for bacteria and number of leucocytes as well as CT-scanning or scintigraphy are the most important diagnostic tools. With rapid and correct antibiotic treatment the prognosis for good or excellent function of the joint is reported to be from 27-90%, while the mortality is reported as being 7-23%.

[Septic arthritis in intravenous drug abuse]

Septic arthritis (SA) in intravenous abusers is reviewed in the English literature from 1966-1992 with the purpose of registration of the bacteriological development, localization of the infected joints, clinical information and laboratory data. Eighty-three publications are available for the review. We have registered 270 joint infections caused by 264 bacteria in 257 intravenous drug abusers with SA. Since 1985 there has been a change in joint localization and bacteriology. A possible explanation is considered. Diagnosis and treatment is difficult, because of the unstable life-style and frequent compliance problems in intravenous drug abusers. SA should be considered in patients with known intravenous drug abuse, uncharacteristic pain and symptoms of osteoarticular infection. SA is often accompanied by fever, leucocytosis and elevated sedimentation rate. Bacteriological diagnosis is achieved by joint aspiration and/or blood culture. Tc-99m-MDP-(technetium-99m-methylene diphosphonate)-bone scintigraphy should be performed on joints suspected of infection which are difficult to aspirate. With adequate antibiotic treatment the prognosis is good, and the mortality is insignificant.

Three-dimensional reconstruction of entire vertebral bodies

This paper describes a technique for 3-D reconstruction of large cancellous bone regions. The output is a 3-D array describing the original cancellous bone region, and the output can be used for any kind of measurement of the bone architecture. The technique was developed as a tool for researchers conducting experimental and clinical studies related to cancellous bone architecture and, ultimately, to cancellous bone quality. A set of new and unbiased methods for quantification of cancellous bone has been a stimulus for the development of the technique, as the quantification methods rely on 3-D information. The technique is based on automated serial sectioning, and all steps from specimen preparation to image segmentation are described in detail. Examples of 3-D reconstructed vertebral bodies are given. By use of the described technique, between 300 and 600 sections can be made and registered per hour, which means that an average vertebral body can be reconstructed in about 2 h. Compared to previous implementations of the general principle of serial sectioning, this is a significant improvement both in resolution and in time efficiency.

Development of a receptor-interaction model for serotonin 5-HT2 receptor antagonists. Predicting selectivity with respect to dopamine D2 receptors

A receptor-interaction model for serotonin 5-HT2 receptor antagonists has been developed by conformational analysis with molecular mechanics (MM2(91)) and superimposition studies of serotonin 5-HT2 receptor antagonists. Substituted 3-(4-piperidinyl)-,1-(4- piperidinyl)-,3-(1,2,3,6-tetrahydropyridin-4-yl)-, and 1-(1,2,3,6-tetrahydropyridin-4-yl)-1H-indoles, substituted 3-(4-fluorophenyl)-1-(4-piperazinyl)indans, cyprohepatadine derivatives, ritanserin, and danitracene have been used as bases for the model. Other serotonin 5-HT2 receptor antagonists, such as ketanserin and MDL 11,939, are well accommodated into the model. Comparison of the model with a recently described receptor-interaction model for dopamine D2 receptor antagonists suggests a common pharmacophore for dopamine D2 and serotonin 5-HT2 receptor antagonists. Important steric differences between 5-HT2 receptor antagonists with additional high affinity for dopamine D2 receptors and serotonin 5-HT2 receptor antagonists with high selectivity versus D2 receptors are described. The geometry of the receptor-interaction model described is significantly different from that of a recently reported receptor-interaction model for 5-HT2 receptor agonists and antagonists developed by use of (+)-LSD as a template, suggesting the existence of two binding modes at the 5-HT2 receptor.

Evaluation of standardized methods for registration of time-dependent orthodontic tooth movements

An in vitro study was conducted to compare reproducibility of repeated recordings obtained from devices constructed for standardized registrations. An existing radiographic method and a new photographic technique were employed. On five in vitro models, half of the maxilla from dry skulls, special designed splints with a Troll-biten film holder were constructed. A stiff metal bar attached to the splints and to either an X-ray apparatus or a standard photographic camera made it possible to obtain standardized registrations. For each model 10 radiographs and photographs were taken before and after the canine was moved. Subtracting the values from well defined points for these pictures, 10 pairs of coordinates were available for each of the models with both methods. The findings showed very similar reproducibility for the two methods with 95 per cent of the discrepancies within a magnitude of 0.12 mm for the radiographic method and 0.14 mm for the photographic method. When evaluating the canine movements, similar results were observed. No significant difference could be detected in the five in vitro models. In addition, the results showed that a splint can be used as a stable reference for registration of tooth movements. Because of ethical objections to unnecessary radiation, the photographic registration technique might substitute the radiographs in future investigations where standardized periodic records are necessary for the description of tooth movement.

[Cor triatriatum with atrial fibrillation as initial symptom in adults]

Cor triatriatum is a rare congenital heart disease. In its classic form its consists of a fibromuscular perforated membrane which divides the left atrium and obstructs blood flow from pulmonary veins to mitral orifice. Clinical symptoms and signs resemble those of mitral stenosis. Traditionally cor triatriatum was encountered most often in infancy and childhood. We describe the case of a young man with cor triatriatum and atrial fibrillation, with syncope. He was operated on with total resection of the obstructing membrane. Modern echocardiography has made diagnosis more easy. Thus, an increasing number of cases of cor triatriatum are diagnosed in adults with few or no symptoms. Symptoms, diagnosis and treatment are discussed, with emphasis on these patients.

Immunological and hormonal responses to lung surgery during one-lung ventilation

The effects of lung surgery performed during one-lung ventilation and the associated endocrine stress response on natural killer (NK) cell activity and the distribution of white blood cells in peripheral blood were studied in 10 patients with malignant lung tumours. Patients were anaesthetized with general anaesthesia combined with thoracic epidural anaesthesia. The endocrine response was measured as changes in serum cortisol, plasma adrenaline and noradrenaline. A significant decrease of NK cell activity was found post-operatively accompanied by leucocytosis, neutrophilia and lymphopenia. Significant increases in serum cortisol were demonstrated at the end of operation and throughout the study period. Plasma adrenaline increased significantly during one-lung ventilation with a gradual normalization post-operatively. Plasma noradrenaline increased significantly during the whole post-operative course. In conclusion, lung surgery was accompanied by similar changes in NK cell activity, leucocyte and differential counts, serum cortisol and plasma adrenaline levels as demonstrated after other types of major surgery. The elevated noradrenaline level post-operatively is a new observation that may be specific for lung surgery.

Hysterothylacium aduncum (Rudolphi, 1862) infection in cod from the Oslofjord: seasonal occurrence of third- and fourth-stage larvae as well as adult worms

Hysterothylacium aduncum infections in cod from the Oslofjord were followed for 1 year. The recovered worms were grouped according to developmental stage [third-stage larvae (L3), fourth-stage larvae (L4) and adult worms] and according to location (in the gut or encapsulated on the viscera). The cod were found to be infected with H. aduncum (all stages lumped) throughout the whole year, with the prevalence approaching 100%. The abundance of the parasites (mean number per fish studied), however, was clearly lowest during the summer months. L3 and L4 recovered from the intestine dominated most of the time but showed a very clear peak during late winter and early spring. L3 recovered from the body cavity was the only stage that showed a clear peak during the summer months. Adult worms, although adult worms were present in very small numbers throughout the year, they tended to peak in May and then again in December and January. Since there did not seem to be a correlation between the accumulation of L3 in the body cavity and the length or age of the fish, the possibility of self-infection whereby the larvae reenter the gut and continue to develop into L4 and then into adults, is discussed.

Selective, centrally acting serotonin 5-HT2 antagonists. 1. 2- and 6-substituted 1-phenyl-3-(4-piperidinyl)-1H-indoles

A series of 1-[2-[4-(1H-indol-3-yl)-1-piperidinyl]ethyl]-2-imidazolidinones has been synthesized. The 1-position of the indole is substituted with phenyl groups and in the 2- or 6-positions are additional substituents. An analogous series with the imidazolidinone ring opened to corresponding urea derivatives was also prepared. High potency and selectivity for 5-HT2 receptors (as compared with D2 and alpha 1 receptor affinities) were obtained with medium-large substituents such as 6-chloro, 6-methyl, and 6-trifluoromethyl or a 2-methyl substituent. Larger 6-substituents such as isopropyl considerably reduced activity, while the smaller 6-fluoro substituent afforded unselective compounds. Selective 5-HT2 antagonists were found by combining 6-substitution with both unsubstituted 1-phenyl and substituted 1-phenyl groups (2-F, 4-F, 4-Cl). However, 3-substitution of the phenyl group markedly reduced 5-HT2 receptor affinity, especially with a 3-trifluoromethyl substituent. Introduction of a 3-(2-propyl) substituent in the imidazolidinone ring reduced binding to alpha 1 adrenoceptors with a factor of 3-8. Practically no influence on 5-HT2 and D2 receptor affinities were found by the presence of this substituent compared to the 3-unsubstituted derivatives. Compounds with potent receptor binding also potently inhibited the quipazine-induced head twitch syndrome in rats. The compounds were equally active after oral and subcutaneous administration and they had a long duration of action (> 24 h). Especially urea derivatives were found to be considerably more potent at 24 h than at 2 h after subcutaneous administration. Some of the compounds potently inhibited isolation-induced aggression in mice, an effect which, however, did not correlate to 5-HT2 receptor-mediated activities. On the basis of these structure-activity studies 1-[2-[4-[6-chloro-1-(4-fluorophenyl)-1H-indol-3-yl]-1- piperidinyl]ethyl]-3-(2-propyl)-2-imidazolidinone (Lu 26-042, compound 4c) was selected for further pharmacological and toxicological investigations.

Selective, centrally acting serotonin 5-HT2 antagonists. 2. Substituted 3-(4-fluorophenyl)-1H-indoles

A series of 3-(4-fluorophenyl)-1H-indoles substituted in the 1-position with 4-piperidinyl, 1,2,3,6-tetrahydro-4-pyridinyl, and 4-piperazinyl was synthesized. By variation of the substituents in the benzene part of the indole nucleus in 1-[2-[4-[3-4-fluorophenyl)-1H-indol-1-yl]-1-piperidinyl]-ethyl]-2- imidazolidinones, the highest 5-HT2 receptor affinity and selectivity with respect to dopamine D2 receptors and alpha 1 adrenoceptors were obtained by 5-methyl substitution. Different substituents were introduced in the 1-position of the piperidine ring in the 5-methyl-substituted derivative. Thus replacement of the 2-(2-imidazolidinon-1-yl)ethyl side chain with a 2-(1,3-dimethyl-1-ureido)ethyl or methyl substituent resulted in unchanged affinity and selectivity for 5-HT2 receptors. Replacement with a 2-[3-(2-propyl)-2-imidazolidinon-1-yl]ethyl side chain reduced binding to alpha 1 adrenoceptors with a factor of four, while affinities for 5-HT2 and D2 receptors were retained, compared to the 3-unsubstituted imidazolidinone. Indoles substituted in the 1-position with 4-piperazinyl had generally weaker affinity for both 5-HT2 and D2 receptors compared to corresponding 4-piperidinyl- and 1,2,3,6-tetrahydro-4-pyridinyl-substituted indoles. Introduction of a methyl group in the 2-position of the 5-methyl-substituted indole resulted in further increase of selectivity for the 5-HT2 receptor. Compounds with potent receptor binding also potently inhibited the quipazine-induced head twitch syndrome in rats. The compounds were equally active after oral and subcutaneous administration and showed a long duration of action (> 24 h). In general, the derivatives were found to be considerably more potent at 24 h than at 2 h after the administration. The compounds within this series were prepared as analogues of the previously described 1-(4-fluorophenyl)-3-(4-piperidyl)-1H-indoles by interchange of the C-3 carbon atom and the nitrogen atom in the indole nucleus. The pharmacological results indicate that this isosteric replacement results in higher selectivity for 5-HT2 receptors compared to the former series. The 1-[2-[4-[2,5-dimethyl-3-(4-fluorophenyl)-1H-indol-1-yl]-1- piperidinyl]ethyl]-2-imidazolidinone has high affinity for 5-HT2 receptors (IC50 = 3.4 nM) and extremely low affinity for both dopamine D2 receptors (IC50 = 6900 nM) and alpha 1 adrenoceptors (IC50 = 2300 nM).

Detection of rhinorrhoea by cisternography in combination with single photon emission tomography, following lumbar injection of iodine-123-labelled albumin

Eight patients were examined. Seven had verified rhinorrhoea and six had had one or more episodes of pneumococcal meningitis. In four of the patients a fistula could not be visualized by computed tomography. All eight patients had injections of iodine-123-labelled albumin by lumbar puncture. Tomoscintigraphy (SPET) was performed 3, 6 and 8-9 h after injection. After 6-8 h we were able to demonstrate a fistula in seven of the patients with verified rhinorrhoea and the findings were confirmed by a subsequent operation. In one of the patients we were not able to visualize any leak of cerebrospinal fluid into the nasal cavity. This patient was not operated upon and we were not able to verify the findings in this patient. The operated patients all did well after the operation with no relapse of meningitis. In conclusion, SPECT-cisternography after intralumbar injection of iodine-123-labelled albumin is a valuable diagnostic tool for the detection of small fistulae in patients with rhinorrhea.

Mediastinal germ cell tumour associated with Klinefelter syndrome. A report of case and review of the literature

A 14-year-old boy with Klinefelter syndrome (KS) and a large mediastinal tumour is presented. Human chorionic gonadotropin and oestradiol were markedly increased. An attempt at radical resection was performed. Histological examination revealed a malignant germ cell tumour of mixed histologic pattern composed of choriocarcinoma and components of mature teratoma. Four courses of cisplatin, bleomycin, and etoposide were given. The patient is without any evidence of tumour recurrence 20 months after diagnosis. A review of the literature revealed another 40 cases of primary mediastinal germ cell tumour (PMGCT) associated with KS. Compiled data from larger series demonstrate that at least 8% of male patients with PMGCT have KS, 50 times the expected frequency. In contrast to PMGCT in patients without KS, all tumours were of nonseminomatous histology, and the average age was considerably lower, Tumours in prepubertal boys were associated with precocious puberty.

Congenital sideroblastic anaemia with intrauterine symptoms and early lethal outcome

Sideroblastic anaemia is a rare disease, which most often presents in early childhood. A case of ringed sideroblastic anaemia with onset in early foetal life in a female infant, resulting in severe intrauterine symptoms, is reported. Six weeks after birth a bone marrow examination revealed a large amount of typical ringed sideroblasts, thus establishing the diagnosis. In spite of repeated blood transfusions, the haemoglobin content gradually decreased. The condition was refractory to pyridoxal phosphate treatment and continued to deteriorate with lethal outcome four months after birth.

The importance of sculpin (Myoxocephalus scorpius) as intermediate host and transmitter of the sealworm Pseudoterranova decipiens

A total of 186 sculpins (Myoxocephalus scorpius) were caught at Vega, Nordland, Norway, and examined for sealworm larvae (Pseudoterranova decipiens). Over 80% of the fish were infected. Very high infections were found with a maximum of nearly 300 larvae in one sculpin. Infections of this magnitude have so far not been reported from sculpins or any other fish species of this size. The importance of the sculpin in the life cycle and in the transmission of P. decipiens to seals or other fish species is briefly discussed.

[Nerve compression symptoms after a long bicycle ride--the Great Test of Strength]

Every year a bicycle-race over 540 km is arranged from Trondheim to Oslo, attracting approximately 5,000 amateur participants. It is well known that nerve compression syndromes may occur in connection with cycling, affecting in particular the ulnar nerve in the Guyon's canal and the pudendal nerve. A questionnaire study was carried out to evaluate the frequency of such complaints (N = 260). 32 (20%) of the 169 cyclists who completed the questionnaire reported numbness in the innervation area for the superficial branch of the ulnar nerve and 11% in the area of the median nerve. Approximately 15% reported paresis in the hand. The problem seemed to be transient. There was a slight tendency towards more symptoms among the most experienced cyclists, indicating that chronic compression may be more serious than the compression related to a single long tour.

[Septic sacroiliitis]

Septic sacroiliitis (SSI) is a rare form of pyogenic arthritis, which unrecognized or inadequately treated may cause longterm morbidity and eventually lasting disability. SSI is most frequently diagnosed among young adults, especially in drug abusers. Based on a literature survey three cases of SSI are presented, each representing characteristic aspects of SSI. The condition should be considered in cases of acute or subacute onset of pain in the gluteal region, hip or low back accompanied by fever. Laboratory findings are variable and non-specific. Definite bacteriologic diagnosis is only achieved in about 75% of the cases. In almost all of the cases, Tc-99m-MDP bone scintigraphy will in almost all the cases show increased uptake in the affected joint within one week after onset of symptoms. Generally antibiotic treatment leads to complete recovery.

Location of centres of resistance for maxillary anterior teeth measured on human autopsy material

The location of the centre of resistance (CR) of various consolidated units of maxillary anterior teeth was determined in this study using human autopsy material. The units studied consisted of two central incisors, four incisors, and six anterior teeth. When horizontal forces were applied the CR for the two- and six-tooth units was located approximately 6.5 mm apical to the bracket position. For the four-tooth unit, CR was placed slightly more occlusally, the distance being 5.0 mm. Applying vertical forces CR was located about 13.0 mm posterior to the bracket position for the two- and four-tooth unit. The incorporation of the canines into the incisor segment resulted in a distal shift of CR of 6 mm. CR for the six anterior teeth was, thus, located on a line 3 mm behind the distal surface of the canines. Increasing force levels had little effect on the location of CR for a given unit.

Rolando's fracture

The relationship between methods of treatment, quality of reduction and the occurrence of late disability and osteo-arthritic changes was studied in 17 Rolando's fractures. Three were undisplaced, 14 were displaced: of these excellent reduction was achieved in five of 11 treated by open reduction and in none of the three treated by percutaneous K wire fixation. After a median interval of 5.8 years, six of 16 reviewed patients had minor symptoms, while nine had no symptoms. Radiographic examination of 11 patients showed signs of osteoarthritis in six. We did not establish a relationship between the quality of reduction and the occurrence of late symptoms and osteoarthritis.

Dietary supplementation with omega-3-polyunsaturated fatty acids decreases mononuclear cell proliferation and interleukin-1 beta content but not monokine secretion in healthy and insulin-dependent diabetic individuals

The effects of dietary supplementation with omega-3-polyunsaturated fatty acids (omega-3-PUFA) on the proliferative response of PBMC and on the secretion of monokines and arachidonic acid metabolites from PBMC and monocytes (Mo) from healthy subjects and patients with recent-onset insulin-dependent diabetes mellitus (IDDM) were examined. Three groups of eight to nine healthy individuals were randomized to either 2.0 g/day or 4.0 g/day of omega-3-PUFA devoid of vitamins A and D, or an isocaloric amount of placebo. Furthermore, eight patients with recent-onset IDDM received 4.0 g/day of omega-3-PUFA. IL-1 beta production and TNF-alpha secretion was determined before and after 7 weeks of treatment, and 10 weeks after withdrawal of treatment. Significant increases in platelet and PBMC membrane eicosapentaenoic acid was found in omega-3-PUFA-treated individuals. omega-3-PUFA treatment significantly reduced the content of IL-1 beta in lysates of PBMC, but did not affect PBMC or Mo secretion of IL-1 beta, TNF-alpha or prostaglandin E2 (PGE2) or PBMC leukotriene B4 (LTB4) secretion in healthy subjects or in IDDM patients. A significant inhibition of the PHA-stimulated, but not the spontaneous or PPD-stimulated, proliferative response of PBMC was observed in healthy and diabetic subjects treated with omega-3-PUFA. No correlation was found between PHA-stimulated PBMC proliferation and PBMC secretion of TNF-alpha and IL-1 beta. There were no significant differences in the spontaneous or the PPD- or PHA-stimulated proliferative responses of PBMC between diabetic and healthy individuals at entry. We conclude that although dietary supplementation with 4.0 g/day of omega-3-PUFA inhibits the proliferation of PBMC and reduces IL-1 beta immunoreactivity in PBMC and Mo, it does not alter monokine, PGE2 or LTB4, secretion in healthy or IDDM subjects.