Polysaccharide storage myopathy

In a woman with a slowly progressive adult onset proximal myopathy, muscle biopsy showed storage of PAS positive material in type 1 fibers. This material consisted of a branched chain polysaccharide associated with a mucoprotein. No abnormality of glycogen-pathway enzymes was detected. This suggested that this polysaccharide accumulation occurred because the polysaccharide was laid down in a non-bioavailable form. The clinical and histochemical features in this patient and in the few similar reported cases indicate that polysaccharide storage myopathy is a distinct entity that is allied to the glycogen storage myopathies.

Autopsy validation of MRI in central pontine myelinolysis

In a fatal case of central pontine myelinolysis (CPM) a low field strength (0.08 Tesla) magnetic resonance image revealed reduction of image intensity in the pons with sparing of two central symmetrical areas in the ventral portion. The latter correlated with preservation of centrally located groups of longitudinal myelinated nerve fibres shown at autopsy. Although such sparing is well recognised in pathological studies of CPM it has never previously been demonstrated in life.

Central motor conduction in multiple sclerosis: evaluation of abnormalities revealed by transcutaneous magnetic stimulation of the brain

Magnetic stimulation of the brain and spinal column was used to assess conduction in the descending central motor pathways controlling arm and leg muscles of 20 patients with multiple sclerosis, and 10 normal subjects. The multiple sclerosis patients had relapsing and remitting disease but all were ambulant and in stable clinical remission. Increased central motor conduction times (CMCTs), up to three times normal, were frequently encountered in multiple sclerosis patients and in leg muscles these correlated closely with clinical signs of upper motor neuron disturbance; in the upper limb muscles a higher proportion of subclinical lesions was present. Weak muscles were almost invariably associated with abnormal central conduction but increased CMCTs were also found for 52 of the 104 muscles with normal strength. CMCTs for lower limb muscles were directly related (p less than 0.005) to functional motor disability (Kurtzke and Ambulatory Index Scales). No patient developed clinical evidence of relapse during follow-up of at least 8 months. Magnetic brain stimulation is easy to perform, painless, and safe, and provides clinically relevant information in the diagnosis and monitoring of multiple sclerosis patients.

Three possible laboratory indexes of disease activity in multiple sclerosis

In a search for an objective measure of disease activity in MS, we studied three laboratory indexes in 15 patients over 12 months, relating them to the occurrence of relapse and the development of increased disability. Relapse was associated with detection of myelin basic protein (MBP) in the CSF (p less than 0.01), but not with decreased numbers of peripheral blood T lymphocytes. Persistently low T-cell numbers and more frequent detection of MBP in remission were associated with increased disability (p less than 0.01). There were no associations between other CSF abnormalities and either relapse or increased disability.

The pharmacokinetics of pyrimethamine in the rat: effect of mefloquine

The pharmacokinetics and tissue distribution of pyrimethamine have been determined in the rat. Following administration of pyrimethamine alone, drug concentrations declined biexponentially. By contrast, in the presence of mefloquine, the decline in pyrimethamine concentration more closely fitted a monoexponential pattern and the AUC0-6h for pyrimethamine was significantly reduced. Significantly more pyrimethamine was recovered from the livers but less from the lungs of the mefloquine-dosed rats compared with control. This study outlines a potentially clinically relevant drug interaction.

Peripheral blood T lymphocyte changes in multiple sclerosis: a marker of disease progression rather than of relapse?

A serial study of peripheral blood T lymphocytes in 27 patients with clinically definite multiple sclerosis and 11 healthy controls was carried out over a 12 month period. This showed that contrary to many previous reports, relapses were not consistently associated with reduced numbers of peripheral blood suppressor T lymphocytes or any other T cells. Persistently low T cells numbers, including both the helper and suppressor T cell subsets, were, however, associated with disease activity as measured by the development of increased disability during the course of the study. This was true both for the patients with relapsing/remitting disease and those with progressive disease. The importance of carrying out a serial study was emphasised by the consistent and significant differences that were detected between individuals in both the control and the patient groups. A serial study is the most reliable means by which clinical events can clearly be correlated with laboratory estimations. The association in this study between the development of increased disability and persistently low levels of peripheral blood T lymphocytes suggest that both may be related to the underlying disease process in multiple sclerosis.

A clinical and laboratory study of benign multiple sclerosis

In a hospital-based study of 400 patients with multiple sclerosis (MS), 42 per cent of patients who had had MS for 10 years or more had benign disease. Early age of onset and a long first remission were significantly associated with a good prognosis. There was a suggestion that initial presentation with paraesthesiae and possibly optic neuritis were associated with a benign prognosis, but the only significant finding was the association between limb weakness and a poor outcome (p less than 0.05). Fewer patients with benign disease had a progressive element to their disease than those in the more disabled group (p less than 0.001). The only laboratory test which was associated with a benign prognosis was the absence of CSF myelin basic protein in remission. Abnormalities of visual evoked response, CSF IgG and peripheral blood T lymphocytes appeared to have no value in assessing prognosis in the patients studied.

Suppressor T cell changes in active multiple sclerosis: analysis with three different monoclonal antibodies

This study demonstrates a significant reduction in the number of both total T cells and suppressor T cells identified by monoclonal antibodies in multiple sclerosis patients in acute relapse but not in those in remission. The reduction in the number of suppressor T cells was shown by all three monoclonal antibodies used but was most clearly demonstrated using Leu 2a rather than either OKT 8 or OKT 5. These findings suggest that the choice of monoclonal antibody used in a study of suppressor T cell numbers will influence the results and may help explain the lack of agreement in previous studies.

Suspected and clinically definite multiple sclerosis: the relationship between CSF immunoglobulins and clinical course

CSF immunoglobulins were examined in 103 patients with clinically definite multiple sclerosis, 106 patients with either suspected or progressive possible multiple sclerosis and 72 patients with other neurological diseases. Raised CSF IgG index and oligoclonal banding were found in 71% and 75% of clinically definite multiple sclerosis patients respectively and both tests were abnormal in 11% of patients with other neurological diseases. The CSF IgG index and the presence of oligoclonal IgG did not relate to the severity or duration of established disease in these patients. In patients with suspected and progressive possible multiple sclerosis, both a raised IgG index and the presence of oligoclonal banding were found significantly more frequently than in the OND group. Abnormalities of these parameters were significantly correlated with the presence of an abnormal evoked response in these patients (chi 2 = 10.16 p less than 0.01). When 47 patients with suspected multiple sclerosis were studied prospectively the presence of oligoclonal banding at presentation was associated with development of further disease activity.

Possible in vivo modulation of Leu 2a expression on suppressor T cells in active multiple sclerosis

Reduced numbers of suppressor T lymphocytes were identified by monoclonal antibodies in the peripheral blood of patients with multiple sclerosis (MS) in acute relapse. In vitro culture of cells from these patients resulted in a significant increase in the number of cells identified with the suppressor T cell marker Leu 2a but not OKT 8. The expression of other T cell antigens (Leu 4 and Leu 3a) remained unchanged. This change in Leu 2a expression did not occur when cells from healthy controls were similarly treated.

Painful Extremities and Neurological Disorder in Essential Thrombocythaemia

Six of 20 patients with essential thrombocythaemia had neurological features and 8 had peripheral vascular symptoms. Four had cerebrovascular ischaemia or stroke and 3 had gangrene. Pain in the extremities may be a striking symptom in this disorder.

Case report: neck injury with quadriplegia: an avoidable training hazard

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Immunofluorescent detection of hormone receptors in cutaneous melanocytic tumours

Immunofluorescent assessment of hormone receptors in melanocytic tumours is quite feasible without loss of diagnostic material, in contrast to the impracticability of quantitative biochemical assays. Using this method, oestrogen receptors were demonstrated in 4/6, and progesterone receptors in 3/5 patients with metastatic melanoma. Receptors were not found in 3 patients with primary cutaneous melanomas of the superficial spreading type. Progesterone receptors were present in the junctional component of a naevus from one healthy person.

Kappa light chain glomerulosclerosis in multiple myeloma

Kappa light chains were demonstrated by immunofluorescence microscopy in the renal basement membranes of 6 of 10 patients with multiple myeloma subjected to kidney biopsy. Nodular glomerulosclerosis was present in 2 of these patients, but the remainder showed only minor light microscopic abnormalities. Deposition of kappa light chains in renal basement membranes may be a frequent cause of kidney disease in multiple myeloma. This deposition may be detected with electron microscopy by the demonstration of granular dense transformation of basement membranes. Occasionally there is systemic vascular deposition of kappa light chains which may be difficult to distinguish from amyloid but lacks a fibrillar character. The tissue effects of light chains in multiple myeloma seem likely to be more extensive than their deposition in renal tubules. There appears to be a greater tendency for kappa light chains to accumulate in renal and systemic basement membranes, but the mechanisms governing this deposition are unknown.

Serum and tissue immune complexes in infective endocarditis

Serial circulating immune complex (IC) determinations were performed in 24 patients with infective endocarditis (IE) using the solid phase Clq, solid phase conglutinin and 3.5% polyethylene glycol precipitation assays. Circulating IC were detected in 67% of IE patients at presentation, but in only 7% of valve lesion controls. Serial determinations produced a 75% prevalence of IC in IE. The presence of circulating IC correlated with "subacute" disease, the presence of tissue deposits of immunoglobulin and/or complement components and with certain extravalvular manifestations (immune complex type glomerulonephritis cutaneous vasculitis and musculoskeletal manifestations). Effective therapy was associated with a fall in circulating IC levels, an effect which was well demonstrated by 3 patients in whom IC rapidly fell to zero following artificial valve replacement. The results support a role for circulating IC in the pathogenesis of this disorder, and suggest that serial IC determinations are useful in following clinical progress, particularly in culture negative endocarditis.

Immunologic studies in IgA nephropathy

Circulating immune complexes (CIC) were detected in 43.6% of 78 patients with primary IgA nephropathy by the solid-phase Clq radioimmunoassay. The IC were intermediate (9 to 17S) in size and contained IgA, IgG, and less commonly IgM. CIC were often present intermittently, correlating with episodes of macroscopic hematuria. Elevated serum IgA concentrations (38.7%) did not correlate with the detection of CIC. Similar findings were observed in sera samples from patients with Henoch Schonlein purpura and in IgA glomerulonephritis associated with alcoholic cirrhosis and/or portal systemic shunts. The factors responsible for the mesangial localization of the IC are not clear, but elevations in serum antibody titers to respiratory pathogens (mycoplasma pneumoniae, herpes virus, influenza), gut flora (E. coli 07), and bovine serum albumin suggest that common exogenous antigens may be involved in the pathogenesis. Primary defects in either mucosal antigen exclusion or reticuloendothelial IC sequestration are proposed to account for these findings.

Vascular IgA deposits in clinically normal skin of patients with renal disease

Direct immunofluorescent tests for IgA deposits were done on biopsies of normal appearing skin from 49 patients with proven renal disease and 7 healthy individuals, in order to evaluate the method in the diagnosis of IgA nephropathy. Many of the 28 patients with IgA nephropathy had high levels of IgA deposition, often accompanied by notable deposits of IgM, Clq and fibrin, and less frequently by C3 and IgG, in small vessels of the superficial dermis. However, some of the 21 patients with other renal diseases had heavy deposits of IgA, limiting the usefulness of the test as a diagnostic aid.

Serum immune complexes and disease

The solid phase Clq radioimmunoassay was used to detect immune complexes in sera from patients with systemic lupus erythematosus (14/25), rheumatoid arthritis (4/5), vasculitis (5/15), infective endocarditis (2/2), acute rheumatic fever (2/3), pre-eclamptic toxaemia (0/14), lung cancer (3/7), glomerulonephritis (26/98) and renal transplant patients (0/5). The best correlation with disease activity was seen in systemic lupus erythematosus and infective endocarditis where serial immune complex determinations were clearly of value in monitoring therapy. The findings in primary glomerulonephritis indicate only a limited usefulness of the assay in that serum immune complexes were detected in a minority (22/73) of patients with glomerular immune deposits. In particular the data do not support a role for Clq fixing immune complexes in the pathogenesis of membranous glomerulonephritis or in pre-eclamptic toxaemia.

Pulmonary actinomycosis in children

The radiological features of three cases of pulmonary actinomycosis in children are presented. Two of the cases had the classical roentgen features of chronic consolidation with overlying rib periostitis. The third had non specific consolidation but demonstrated extension through the diaphragm. Two of our cases were mentally subnormal children in institutional care. Their pulmonary pathology is almost certainly attributal to poor dental hygiene, a constant problem in this group of children. Hence, although pulmonary actinomycosis is rare in the general populus, we suggest it might be suspected more often in the subnormal group when chronic consolidation is present.

Pneumatosis coli in non-Hodgkins lymphoma

Two patients with poorly differentiated lymphoma who developed pneumatosis coli are described. In one case, the intramural gas was associated with diffuse nodular submucosal deposits of tumour. An annular stricture due to lymphoma was the underlying aetiology of the pneumatosis coli in the second case. The pathogenesis of pneumatosis coli in the context of malignant lymphoma is discussed.

Lymphoma of the colon: the spectrum of radiologic changes

Primary lymphoma of the colon is rare and comprises less than 1% of large bowel malignancies. Secondary colonic involvement in patients with advanced lymphoma is not uncommon and is frequently undetected. The radiographic findings of 34 patients with colonic lymphoma were reviewed. Thirteen patients had primary tumors, while the remaining 21 had colonic involvement secondary to systemic disease. The radiologic features were classified as mucosal nodularity, endo-exoenteric mass, intraluminal mass, mural infiltration, and mesenteric invasion. One patient with diffuse mucosal nodularity developed acute colonic dilatation, while two other patients had pneumatosis coli secondary to local tumor depositions. Lymphoma is now a well-described complication of chronic ulcerative colitis, and a further case is described here. Although colonic lymphoma is a relatively rare tumor, the spectrum of radiologic changes reviewed here may enable a more accurate radiologic diagnosis.

Children's comprehension of time-compressed speech: effect of speaker's familiarity

An experiment was conducted with 42 third grade children from a parochial school system in a large metropolitan area. 21 classmates whose teacher served as the speaker for this experiment comprised the experimental group. A matched group of 21 classmates from another third grade classroom formed the control group. Each subject individually listened to a 940-word narrative passage that had been compressed at a rate of 45% or 275 words per minute. 10 questions about the material presented in the final three-fourths of the passage were asked of the subjects. The difference between the mean number of correct responses produced by the experimental group (5.5) and the control group (4.9) was not statistically significant. The results indicate that familiarity with the speaker does not facilitate 8-yr.-olds' comprehension of time-compressed speech.

IgA nephropathy: a syndrome of uniform morphology, diverse clinical features and uncertain prognosis

Isolated glomerulonephritis with mesangial IgA deposits was the most common single finding encountered in a large biopsy series in an Australian community and was found in 50 patients, 18% of those presenting for the investigation of primary glomerular disease. A uniform histopathological picture of mesangial enlargement, with or without focal and segmental features was present. A tendency to progression was suggested by the frequent presence of glomerulosclerosis, interstitial scarring and vascular hyalinization. Because of the uniform histological immunofluorescence and ultrastructural appearances, the term IgA nephropathy has been used for this condition. The clinical picture, however, was heterogenous. Presenting symptoms included macroscopic hematuria (34%), proteinuria (32%) acute nephritis (10%), nephrotic syndrome (6%), malignant hypertension (8%), acute renal failure (6%) and chronic renal failure (4%). There was a striking correlation of increased blood pressure and decreased renal function with increasing age. While the period of follow-up was too short to assess individual patient data, a gradual and progressive decrease in renal function over several decades is suspected in patients with this condition.

The association of elevated plasma cortisol and early atherosclerosis as demonstrated by coronary angiography

To study the association of plasma cortisol and coronary atherosclerosis, we elected 71 male outpatients who had coronary angiography as part of their evaluation at our facility. Forty-eight percent of the angiograms showed no evidence of coronary artery disease (CAD), 20% showed mild CAD, and 32% showed moderate to severe CAD. We found significant correlations between elevated serial morning plasma cortisols and moderate to severe coronary atherosclerosis. Using the odds ratio, we compared plasma cortisol to the major risk factors for coronary artery disease. Plasma cortisol was second only to serum cholesterol as a discriminator in our patient population between diseased and non-diseased patients. We found a significant correlation between plasma cortisol and cholesterol, blood pressure, and smoking- the three cardinal risk factors for CAD. The highest degree of correlation was found between cortisol and cholesterol. The possible significance of the association of cortisol and the major risk factors for CAD is discussed.

Angiographic findings in asymptomatic aircrewmen with electrocardiographic abnormalities

Cardiac catheterization was used to evaluate 298 asymptomatic, apparently healthy aircrewmen with electrocardiographic abnormalities. These men were identified from annual electrocardiograms and exercise tests used to screen for latent heart disease. Data from 27 additional symptomatic aircrewmen who underwent cardiac catheterization because of mild probable angina pectoris are also included. The men were grouped according to major reason for cardiac catheterization. The order of groups by increasing prevalence of coronary artery disease was as follows: abnormal treadmill test (labile lead only), supraventricular tachycardia, right bundle branch block, left bundle branch block, abnormal treadmill test, ventricular irritability, probable infarct and angina. Approximately 60 percent of the men were completely free of angiographic coronary artery disease. Risk factors and other possible causes for the electrocardiographic abnormalities are discussed. The electrocardiographic abnormalities studied have a poorer predictive value for coronary artery disease in asymptomatic apparently healthy men than in a hospital or clinic population.

Value of exercise testing for screening asymptomatic men for latent coronary artery disease

Treadmill exercise testing identifies a group of men at high risk for coronary atherosclerotic heart disease. However, the predictive value and sensitivity limitations are obvious. An abnormal electrocardiographic response does not absolutely predict the presence of coronary atherosclerotic heart disease, and a normal response does not rule out this possibility. Thus in appropriate instances when the minimal risk of coronary angiography is justified this procedure can be used to determine the anatomic correlation of exercise-induced functional ST-segment changes.

Prediction of maximal oxygen consumption. Comparison of the Bruce and Balke treadmill protocols

This study investigated the hypothesis that an individual's maximal oxygen consumption can be realistically predicted by the maximal time achieved in the Balke or Bruce treadmill protocols. The range of maximal oxygen consumption that can be expected for healthy individuals of any given age and activity was also evaluated. The maximal oxygen consumptions achieved by 79 men exercised using the Balke protocol and 77 men using the Bruce protocol were linearly regressed by a least-squares fit technique on maximal treadmill time and on age with activity status classified. Statistical analysis demonstrated an inadequate relationship for predicting maximal oxygen consumption from maximal treadmill time using either protocol. Also, maximal oxygen consumption correlated poorly with age even though activity status was considered. These findings make the nomogram for predicting an individual's functional aerobic impairment a clinical technique of questionable value. Since maximal oxygen consumption can only be grossly estimated from the maximal time performed in the Bruce or Balke protocols, there is no necessity to use them in preference to other clinically acceptable protocols.

Normal coronary angiography in an aircrewman with serial exercise test changes

A 45-year-old asymptomatic aircrewman is presented who developed an abnormal ST segment response to maximal treadmill testing after normal responses for 3 previous years. Coronary angiography performed after his abnormal stress test reveled no change from a previously normal study. It has been demostrated that serially performing exercise tests can increase the sensitivity of detecting latent coronary artery disease. The importance of the case report is to demonstrate that the change from a normal exercise test to an abnormal one does not absolutely indicate that an individual has a coronary artery disease and that it is mandatory to search for other possible causes. Further studies will be required to determine the significance of such serial changes.

The nature and properties of the inducible sodium-plus-potassium ion-dependent adenosine triphosphatase in the gills of eels (Anguilla anguilla) adapted to fresh water and sea water

1. Gill tissue from eels adapted to fresh water or to sea water was disrupted in 0.32m-sucrose containing 0.1% (w/v) sodium deoxycholate and the subcellular distribution of (Na(+)+K(+))-dependent adenosine triphosphatase was determined. 2. About 70% of the recovered enzyme was in a fraction sedimenting between 225000g(av.)-min and 6000000g(av.)-min; the specific activities of enzymes from tissues of freshwater and seawater eels were 16 and 51 mumol of phosphate/h per mg of protein respectively. 3. The enzymes from gills of freshwater and seawater eels were indistinguishable on the basis of a number of parameters. These included phosphorylation by [gamma-(32)P]ATP, the binding of [(3)H]ouabain, the extent to which bound [(3)H]ouabain was displaced by increasing concentrations of KCl and pH optima. 4. Electrophoresis on polyacrylamide gels in sodium dodecyl sulphate showed that enzyme preparations from both sources had an identical number of protein components. 5. The higher specific activity of (Na(+)+K(+))-dependent adenosine triphosphatase from tissue of seawater eels was accompanied by increased amounts of two protein components. One of these proteins retained (32)P after treatment of the enzyme with [gamma-(32)P]ATP and had mol.wt. 97000; the other component was a glycoprotein with mol.wt. approx. 46000. 6. The results are discussed in terms of the nature of the transepithelial NaCl pumps in the gills of freshwater and seawater fish.