Acute meningitis and cerebellar dysfunction complicating high-dose cytosine arabinoside therapy

A patient with acute lymphocytic leukemia (ALL) who was treated with high-dose cytosine arabinoside (Ara-C) 3 g/m2 twice daily, developed reversible acute aseptic meningitis and signs of cerebellar dysfunction after a total dose of 24 g Ara-C. To our knowledge this is the first case report of meningitis complicating intravenous high-dose Ara-C therapy.

Islet cell autoantibodies in African patients with Type 1 and Type 2 diabetes in Dar es Salaam Tanzania: a cross sectional study

Background

The aim of the present study was to assess the occurrence of glutamic acid decarboxylase autoantibodies (GADA) and insulinoma antigen 2 autoantibodies (IA2A) among patients of African origin in Dar es Salaam, Tanzania and to compare the occurrence of autoimmune mediated Type 1 diabetes with findings previously reported from the same place and from other African diabetic populations.

Methods

Two hundred and forty five patients from the diabetic clinic at Muhimbili Hospital were recruited for a cross sectional study. Patients were clinically classified into groups with Type 1 (T1D) and Type 2 diabetes (T2D); there were 94 patients with T1D and 151 with T2D. Autoantibodies for GAD and IA2 were measured with an assay based on radioligand binding. Fasting and random blood glucose, HbA1c, and C-peptide levels were also determined.

Results

Of the patients with T1D, 28 (29.8%) were GADA positive and 20 (21.3%) were IA2A positive. The overall occurrence of any autoantibody was 42.6%. The GAD and IA2 autoantibodies were detected more frequently among patients with T1D than among patients with T2D (P < 0.001). A higher autoantibody prevalence was observed with combined GADA and IA2A measurements compared to individual autoantibody measurements; 40 (42.6%) patients with T1D versus 11 (7.3%) with T2D had at least one positive autoantibody titer. There was no correlation between duration of disease and detection of autoantibodies in patients with T1D. There was a strong association with family history of diabetes among the autoantibody positive versus autoantibody negative patients with T1D (p < 0.01).

Conclusion

The prevalence of GAD and IA2 autoantibodies among African patients with T1D in Dar es Salaam was the same as that reported previously for South Africa and Ethiopia. It was much higher than the prevalence of islet cell autoantibodies (ICA) reported from the same clinic about 15 years ago. For unknown reasons the prevalence of pancreatic related autoantibodies in this African population is lower than the prevalence found among Caucasian populations.

Dead-in-bed syndrome in young diabetic patients

The so-called dead-in-bed syndrome refers to sudden death in young diabetic patients without any history of long-term complications. Autopsy is typically negative. The present report summarizes frequency data on this condition from studies in the U.K. and the Scandinavian countries. It appears that such deaths occur in 6% of all deaths in diabetic patients below age 40 years. The frequency may also be expressed as 2-6 events per 10,000 [corrected] patient-years. The causes are by definition unknown, but a plausible theory is a death in hypoglycemia, since a history of nocturnal hypoglycemia is noted in most cases. While waiting for the clarification of the underlying pathophysiology, one should attempt to identify patients who are at particular risk of hypoglycemia and advocate caution in efforts to normalize blood glucose and HbAlc in these cases.

[Scintigraphic localization of ectopic parathyroid tissue]

Ectopic parathyroid adenomas and hyperplastic glands are difficult to locate during surgical exploration. Failure to find and remove them is the most usual cause of surgical failure in the treatment of hyperparathyroidism. Earlier methods of preoperative localization of pathological parathyroid tissue had low sensitivity and were not generally recommended. Recent advances in parathyroid scintigraphy have improved this technique; the sensitivity is now as high as 95% for parathyroid adenomas. In the present study, ectopic parathyroid adenomas and hyperplasia were correctly localized by scintigraphy and were verified surgically in seven patients. Six of the patients had previously undergone ten unsuccessful operations altogether. Preoperative parathyroid scintigraphy might have saved these failed surgical explorations. In a pregnant woman, a mediastinal parathyroid adenoma was correctly localized by preoperative parathyroid scintigraphy. This patient was successfully operated by a sternotomy, and she was the only one of five patients with a mediastinal parathyroid adenoma who escaped unnecessary neck exploration. Preoperative parathyroid scintigraphy may reduce the number of surgical failures in hyperparathyroidism and shorten the operation time by less extensive exploration and thus fewer complications.

[Diabetes mellitus in pregnancy]

The authors highlight some aspects of diabetes mellitus that complicate pregnancy. Several complications, e.g. hypoglycaemia, hyperglycaemia and macrosomia are described briefly. Macrosomia can be diagnosed by ultrasound examination, which should be performed every other week from the 24th week of gestation. Accelerated abdominal circumference (> or = 1.2 cm/week) between 32 and 39 weeks and excess thickness of soft tissue over the proximal humerus of the foetus after the 32nd week (> 13 mm at term) may imply development of macrosomia. The elevated risk related to adiposity and poor metabolic control can be avoided by intensive treatment. Intensive metabolic treatment can also reduce the frequency of preeclampsia and polyhydramnion. Ketoacidosis and intrauterine foetal death may be consequences of poor diabetic control. The authors discuss infectious problems, some aspects of treatment, e.g. risk of preterm delivery, dietary treatment and insulin, indications for delivery and various neonatal problems.

[Pregnancy in diabetes]

The authors review various aspects of gestational diabetes, including definition, screening, diagnostic procedures, complications (hypertension, macrosomia), clinical evaluation (ultrasound, non-stress test), treatment (diet, insulin), indications for delivery and neonatal aspects (hypoglycaemia, hypocalcaemia). Complications can be reduced by intensive dietary treatment and insulin. If the gestational diabetes is regulated well the woman can wait for spontaneous birth at term. In the case of pregnant women with less than optimal regulated diabetes, however, or with complications such as hypertension, macrosomia, previous stillbirth, labour can be induced preterm by local administration of prostaglandin or infusion of oxytocin. Physical training and weight reduction should be instituted to avoid later development of type II diabetes mellitus. There is still some uncertainty about different aspects of gestational diabetes.

Dead in bed syndrome in young diabetic patients in Norway

The incidence of unexplained deaths ('dead in bed syndrome') in Norwegian diabetic patients under the age of 40 was investigated during the period 1981-1990. During this 10-year period there were 240 deaths of all causes in the age group 0-39 years. Sixteen of these cases fulfilled the following criteria of the 'dead in bed syndrome': (1) patient found dead in an undisturbed bed; (2) patient observed to be in good health condition the day before; (3) no clinical evidence of late complications (except background retinopathy in two cases). Of the 16 cases ascertained, 10 were males and 6 females. The age range was 7-35 years, and the duration of diabetes varied between a few months and 26 years. Autopsy, performed in 13 cases, did not reveal any cause of death. Nine patients had been using insulin regimens with multiple daily doses. Twelve patients were reported as having had frequent episodes of hypoglycaemia, with nocturnal episodes in 10 cases. There was apparently an increasing incidence of unexplained deaths during the study period, with 12 of 16 cases occurring in the years 1988 to 1990.

Osteopenia caused by heparin treatment in pregnancy

A case is reported of severe osteopenia caused by heparin treatment of thrombosis in the eleventh week of pregnancy followed by heparin prophylaxis (5000 IU three times daily) during pregnancy and lactation. The mother complained of back pain during the last two weeks of pregnancy. Six weeks post partum, generalized osteopenia in the skeleton was diagnosed and a compression fracture of the body of the sixth thoracic vertebra. During pregnancy the mother had relatively low serum concentrations of 1,25(OH)2D, the active metabolite of vitamin D, and six weeks after delivery the serum concentration had fallen to about 50% of the lowest reference level. Eight and fourteen weeks after delivery, when heparin treatment had been discontinued, the serum concentrations of 1,25(OH)2D were within the reference range for non-pregnant adults.

Calcium homeostasis in pregnancy and lactation

This paper discusses different aspects of calcium homeostasis in pregnancy: the calcium demands of the mother, regulation mechanisms and the risk factors for demineralization. Special care should be paid to patients lying in bed for long periods and patients given heparin prophylaxis. One to two grams of calcium and 400 IU of vitamin D daily should be given orally to patients who are being treated for deep vein thrombosis. In addition, bone density should be checked to detect osteoporosis. The period of heparin prophylaxis must be as short as possible and bed rest must not be unnecessarily prolonged.

[Rapid calcium infusion in the diagnosis of hypoglycemia]

The diagnosis of beta cell tumours of the pancreas is a clinical problem. It is also difficult to exclude this diagnosis in patients who are suspected of suffering from recurrent hypoglycemia, but do not have beta cell tumours. The most widely used diagnostic procedure has been suppression of endogenous insulin production with prolonged fasting up to 72 hours. This procedure is troublesome to the patient, time-consuming and expensive, and demands the complete cooperation of the patient. Therefore several diagnostic tests have been developed, but none has been generally accepted. A newly described test involving calcium infusion, 2 mg/kg in one minute, seems to give a diagnostic response in most patients with insulinomas, few false positive results and few side effects. We have used this test for four years and found it safe and easy to perform. It has given diagnostic response in three patients with insulinomas and no false positive results in 27 other patients.

Aortic stiffness in insulin-dependent diabetics: an echocardiographic study

To assess the aortic stiffness (AS) in young (15-35 year old) insulin-dependent diabetics without manifestations of atherosclerotic disease or hypertension, M-mode echocardiography was used to measure relative changes in aortic diameter expressed as Aortic strain = Diameter change/Diastolic diameter-100% Aortic stiffness can be calculated from the formula AS = Pulse pressure/Aortic strain. Fifty-seven diabetics were investigated, 31 men (aged 23.6 +/- 5.6 years, mean +/- SD) and 26 women (aged 25.7 +/- 6.4 years). There were 26 healthy controls with similar blood pressure, 14 men (aged 25.0 +/- 5.5 years) and 12 women (aged 24.6 +/- 7.1). The AS in diabetic men was 14 +/- 8.0 (mean +/- SD) compared to 3.6 +/- 0.7 in controls (p less than 0.001). In diabetic women the AS was 5.8 +/- 3.1 compared to 4.3 +/- 1.3 in controls (p less than 0.05). Diabetic men also had much stiffer aortas than diabetic women (p less than 0.001). There was a linear correlation between AS and duration of diabetes in men (R = 0.70; (p less than 0.001). For females no such correlation was found, the AS frequently being within the range of the controls in spite of long duration of the disease. In males there was a significant correlation between AS and retinopathy (R = 0.49; p less than 0.01) and an inverse correlation with HDL-cholesterol/total cholesterol ratio (R = 0.51; p less than 0.01). In diabetic females AS was significantly greater in smokers (7.0 +/- 3.7) than in non-smokers (4.2 +/- 2.2; p less than 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)