Primary Whipple's disease of the brain: characterization of the clinical syndrome and molecular diagnosis

BACKGROUND

Whipple's disease (WD) of the brain without evidence of systemic involvement is a rare illness that is difficult to recognize and potentially life-threatening.

AIM

To elucidate the clinical features and diagnosis of primary WD of the brain.

DESIGN

A single case study, with review of published data.

METHODS

We linked the information about our patient with 956 citations to published WD material. We were able to identify 19 other patients with primary WD of the brain.

RESULTS

Our patient was a 48-year-old woman who presented 2 years ago with generalized tonic/clonic seizures. WD of the brain was diagnosed after a life-threatening subacute deterioration leading to reduced consciousness and eye movement abnormalities. She had atrophy and gliosis of the right hippocampal formation, and nodular enhanc-ing lesions. She developed the syndrome of inappropriate ADH secretion, blepharospasm with a complete paralysis of vertical gaze, a severe amnesic syndrome, obstructive sleep apnoea, altered sleep physiology and CSF oligoclonal bands. Primary WD of the brain was diagnosed after PCR confirmed Tropheryma whipplei DNA in CSF and blood. She recovered after intravenous methylprednisolone, meropenem and cotrimoxazole. She has now survived for 24 months, lives independently and drives. Comparing our patient with the 19 others, two clinical syndromes were apparent, in both adults and children: (i) multifarious neurological symptoms and signs with a CT or MRI showing multiple nodular enhancing lesions; (ii) focal neurology secondary to solitary mass lesions.

DISCUSSION

Primary WD of the brain may be diagnosed by recognition of these two clinical syndromes, and confirmed by the application of molecular biological techniques such as PCR.

Renal vasculitis: increasingly a disease of the elderly?

BACKGROUND/AIMS

The majority of patients presenting to our district general hospital with renal vasculitis are elderly. Older patients respond less well to treatment and have a poorer prognosis. We investigated the relationship between age and outcome of renal vasculitis in our centre and examined the evidence regarding treatment of elderly patients with this condition.

METHODS

Patients presenting over a 2-year period with renal vasculitis were identified by clinical and histological features and by antineutrophil cytoplasmic autoantibody positivity. They were followed for a mean of 15 months and outcomes were recorded. Results were compared with published studies.

RESULTS

The mean age at presentation of 21 patients was 69 years. Forty-eight percent required dialysis and there was a 33% overall mortality. The mean age of patients in previous treatment studies has been between 50 and 55 years.

CONCLUSIONS

The greater severity of disease at presentation and poorer outcome than previously described is likely to be due to the high proportion of elderly patients. The incidence of vasculitis is increasing in the elderly but as this group has been poorly represented in clinical trials in renal vasculitis, applying the findings of these trials to their treatment may be hazardous. Future research should determine which treatments are safe and effective in the elderly.

Nurse practitioners' perceptions of their caring behaviors

PURPOSE

To explore nurse practitioners' (NPs) perceptions of their own caring behaviors, the relationship between sociodemographic variables, environmental factors, and NP's perceptions of their caring behaviors.

DATA SOURCES

A mailed survey to a systematic random sample of 200 members of an Illinois NP group.

CONCLUSIONS

The top ten caring behaviors in rank order were appreciating the patient as a human being, showing respect for the patient, being sensitive to the patient, talking with the patient, treating patient information confidentially, treating the patient as an individual, encouraging the patient to call with problems, being honest with the patient, and listening attentively to the patient.

IMPLICATIONS FOR PRACTICE

The quality of instruction in the biomedical aspect of nursing education is relatively easily assessed. Caring is nurses' hidden work that may go unrecognized except when the caring behaviors are missed by the patients or their families.

An unusual cause of an 'acute abdomen'

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Peripheral microvascular parameters in the nephrotic syndrome

BACKGROUND

Peripheral edema, in combination with severe proteinuria and low serum albumin levels, is pathognomonic of the nephrotic syndrome, yet the exact mechanism of its formation is unknown. Two of the most important of the factors in Starling's forces controlling fluid filtration across the capillary have hitherto not been studied in nephrotic subjects.

METHODS

The hydrostatic capillary pressure at the finger nail-fold in actively nephrotic subjects and age and sex matched controls was studied, using direct puncture of the apex of the capillary under video microscopy, and a servonulling apparatus to give a direct measurement of capillary pressure. Capillary filtration capacity (CFC) at the calf was measured noninvasively by a modern derivative of the technique of mercury strain gauge plethysmography. Fifteen nephrotic subjects with a variety of underlying pathological lesions, and age matched controls were studied.

RESULTS

Contrary to the assumption of the "overflow" hypothesis of edema formation, there was no evidence of capillary hypertension. The capillary pressure showed no difference between nephrotic subjects and controls: median (range) of 17.6 (12.0 to 24.2) compared with 17.3 (9.0 to 21.6) mm Hg, P = NS. CFC was significantly higher in nephrotic subjects than controls [5.23 (3.28 to 8.52) x 10(-3) versus 3.55 (2.43 to 5.28) x 10(-3) ml/min/100 g/mm Hg, P < 0.01].

CONCLUSIONS

An increase in CFC provides a potentially novel mechanism contributing at least in part to the formation of peripheral edema in the nephrotic syndrome.

Dose titration during anti-thymocyte globulin therapy: monitoring by CD3 count or total lymphocyte count?

Anti-thymocyte globulin (ATG) is extensively used for both prophylaxis and treatment of rejection episodes in renal transplantation, but it is expensive and potentially hazardous. We report the utility of therapeutic monitoring by the readily available total lymphocyte count, compared with the more complex and expensive assay of CD3 counts by flow cytometry in eight renal transplant patients receiving ATG. Aiming for an absolute CD3 count of 0.2-0.5 x 10(9)/l, it was possible to reduce the mean daily dose of ATG from the recommended 2.5 mg/kg/d to a mean of 1.6 mg/kg/d. Analysis of simultaneously taken total lymphocyte counts showed that the same dose reductions could have been made if the target for therapeutic effect had been a total lymphocyte count of < 0.3 x 10(9)/l. Anti-rejection therapy was successful in all cases, with satisfactory graft function at 6-9 months post-therapy. Lower than recommended doses of ATG proved effective prophylaxis and treatment of renal allograft rejection, with considerable cost savings. A simple protocol may be followed titrating dose against total lymphocyte count, provided it remains below 0.3 x 10(9)/l. CD3 estimation can be reserved for those times when the total lymphocyte count rises to 0.3 x 10(9)/l or above.

Capillary filtration coefficient and urinary albumin leak at altitude

Rapid ascent to altitude risks the development of acute mountain sickness. This study demonstrates changes in peripheral capillary filtration coefficient and renal protein loss in subjects suffering from various degrees of mountain sickness after passive ascent to 4559 m. Capillary filtration coefficient of the calf capillary bed, measured by computer-based multistep strain gauge plethysmography, increased significantly after 23.5 h at altitude when symptoms were most severe: 4.45 (2.76-6.03) to 6.31 (3.86-11.07) ml min(-1) per 100 g of tissue mmHg(-1), median (range) (P < 0.02). Urinary albumin excretion was increased after one night at altitude from 1.1 (0.6-1.5) to 2.45 (1.0-6-8) mg of albumin per mmol of creatinine (P < 0.05). These results demonstrate simultaneous leakage of a peripheral capillary bed to fluid measured by strain gauge plethysmography, and renal albumin leak, and suggest a systemic process of increased capillary leakage for different-sized molecules caused by rapid exposure to hypobaric hypoxia.

Nurses' attitudes and behaviors that promote breastfeeding

This descriptive correlation study determined the attitudes and behaviors of obstetrics nurses toward breastfeeding and early lactation. Maternity nursing staff at 20 Midwestern hospitals, representing all levels of prenatal care in urban and rural settings, voluntarily answered a 19-item questionnaire. A total of 230 anonymous responses were received. Sixty-four percent of the nurses would recommend or actively encourage breastfeeding and were very interested in helping a woman learn how to breastfeed. Time factors, including shortened length of stay, and lack of knowledge were perceived to be the primary barriers for nurses in assisting mothers to breastfeed. Nurses who cited length of stay as a barrier had more years in obstetric nursing (p < .05). Level of nurses' education correlated positively to active encouragement and support of breastfeeding (p = .024), as well as personal breastfeeding experience (p = .02). The average discharge breastfeeding rate at the study hospitals was 40 percent, well below the national average of 56 percent. Both education and personal experience influence the nurse's attitudes and behaviors in the promotion of breastfeeding. These nurses perceived breastfeeding support as too time-consuming, which suggests that they have not fully adapted to shorter obstetric stays. Nurses need support and continuing education to identify personal bias and knowledge deficits which hinder breastfeeding promotion.

Classical versus non-renal Wegener's granulomatosis

We investigated whether 'limited' or 'non-renal' Wegener's granulomatosis (WG) differs from classical or 'renal' WG. Renal WG is characterized by necrotizing granulomatosis of the upper and or lower respiratory tract, accompanied by systemic vasculitis and focal segmental necrotizing glomerulonephritis. This last feature is absent in non-renal WG. In a prospective follow-up study of all identified cases presenting to a single teaching hospital, we reviewed 22 patients with non-renal WG, and compared their presentation and outcome with that of 28 patients with renal WG. Clinical and laboratory assessment of disease activity, frequency of death, relapse and end-stage renal disease were assessed. The two groups differed in clinical presentation, laboratory features and outcome. The group with non-renal WG had less cutaneous and pulmonary disease; the haemoglobin, white cell count and platelet count tended to be normal. Residual mortality was confined to the renal group. However, the groups shared many features, particularly their requirement for immunosuppressive therapy, since WG causes major tissue destruction regardless of whether it is a localized or widespread process. At the immunopathological level, the two groups appear to be part of a single disease spectrum. Importantly, the non-renal WG group may change the pattern of their disease to involve the kidney. Long-term follow-up of such patients is therefore essential.

A Target Weight Procedure for Disordered Water Balance in Long-Term Care Facilities

1. Water intoxication is a severe complication of disordered water balance. Hyponatremia precedes water intoxication and can be identified through abnormal diurnal weight variation. 2. The St. Louis Target Weight Procedure (STWP) is a nonintrusive method that includes a client's baseline weight, frequent weights throughout the day, a target weight of 5% above the baseline weight, and restricted fluids if the target weight is exceeded. 3. The STWP was positively related to an increase in urine concentration; thus it is successful in restoring normal fluid balance.

Neurotoxicity associated with oral acyclovir in patients undergoing dialysis

Neurotoxicity associated with intravenous acyclovir therapy is well documented. We report 4 cases of acyclovir-induced neurotoxicity in dialysis patients receiving oral therapy at a reduced dose.

Wegener's granulomatosis occurring in siblings

A brother and sister sibling pair with Wegener's granulomatosis (WG) are described. Previous reports of familial WG are reviewed.

Prognostic factors in acute renal failure following aortic aneurysm surgery

This study analyses the prognostic factors associated with survival in 70 patients who developed acute renal failure following surgery for an aortic aneurysm. Forty-nine patients (70 per cent) had surgery for a ruptured aortic aneurysm and 21 patients (30 per cent) had an elective procedure. Fifty-nine patients received haemodialysis. Thirty-three patients (47 per cent) survived the episode of acute renal failure. Six of these thirty-three patients died within three months of recovering from acute renal failure, giving an overall survival of 27/70 (39 per cent). A stepwise logistic regression analysis showed that the following factors significantly adversely affected survival: a need for inotropic support, ventilation for more than three days and age over 65 years. A model developed using these variables provided a basis for predicting outcome.

Chronic ambulatory peritoneal dialysis in patients aged over seventy

Thirteen patients with end-stage renal disease aged 70 years have been successfully treated by chronic dialysis treatment. Despite many problems associated with the elderly, a good quality of life was achieved.

Different types of segmental sclerosing glomerular lesions in six experimental models of proteinuria

From 133 to 615 glomeruli were examined in sections of kidneys from each of 60 animals, representing six rodent models of proteinuria. Particular attention was paid to the position of segmental lesions. Lewis rats given sheep anti-rat glomerular basement membrane antibodies had lesions almost exclusively at the glomerulo-tubular junction. Wistar rats on a diet of 24 per cent casein or with subtotal nephrectomy and a diet of 24 per cent soya had lesions mainly at the hilum. Wistar rats given bovine serum albumin had global lesions but virtually no segmental lesions. Wistar rats given puromycin aminonucleoside had lesions at the glomerulo-tubular junction and global mesangial abnormalities shortly after the treatment but later developed segmental lesions at all parts of the glomerulus. Untreated BUF/Mna rats had lesions at the glomerulo-tubular junction early in life but later had lesions at all parts of the glomerulus. Untreated NZB/NZW hybrid mice had various types of glomerulonephritis and also had lesions at the glomerulo-tubular junction. These findings showed that (1) segmental lesions at the glomerulo-tubular junction, or glomerular tip, occur in experimental animals, a fact not previously reported, and these tip changes are a common feature in several different models of proteinuria; (2) hilar segmental lesions are seen in conditions with hyperfiltration of protein; and (3) segmental lesions at various parts of the glomerulus are seen in some models of proteinuria and probably indicate late effects of random toxic damage to the glomerulus. Thus, there are at least three different types of segmental glomerular lesions in experimental animals--tip, hilar, and random--with different morphology and pathogenesis. It is likely that these findings can be extended to human renal diseases with segmental glomerular lesions. This will help to clarify the controversial and unsatisfactory term focal segmental glomerulosclerosis.

How to perform a renal biopsy

A percutaneous renal biopsy is an important investigative procedure in many patients with renal disease. The procedure described below is easy and safe to perform in competent hands, but requires experienced histological support if clinical management is to be optimal.

The treatment of diabetic renal failure by continuous ambulatory peritoneal dialysis

During the 6-year period 1981-1987, 309 patients started chronic ambulatory peritoneal dialysis (CAPD), of whom 75 (24%) had diabetes. Despite severe peripheral vascular problems (20%), ischaemic heart disease (90%), and complete blindness (21%) the 1-year patient survival on CAPD was 88%. The actuarial patient survival for diabetic patients was similar to that of the non-diabetic cohort over the first 18 months but fell to 48% (compared to 70% in non-diabetic patients) at 3 years. Complications associated with CAPD, including the incidence of peritonitis, were no different between the diabetic and non-diabetic patient populations. Successful treatment for end-stage renal disease (ESRD) in diabetic patients can be achieved and justified in a liberal selection programme for the treatment of diabetic ESRD.

T-cell-independent and T-cell-dependent antibody responses in patients with chronic renal failure

Antibody responses against pneumococcal capsular antigens and tetanus toxoid were measured in 14 patients with chronic renal failure who were managed by continuous ambulatory peritoneal dialysis (CAPD) or haemodialysis (HD) and in eight healthy controls. IgG antipneumococcal responses were predominantly of the IgG2 and to a lesser extent IgG1 subclasses, while the IgG response against tetanus toxoid was largely IgG1 with smaller amounts of IgG4 and IgG3. The post-immunisation serum levels of IgG1 and IgM antibody against both antigens were significantly reduced in the uraemic patients compared with controls (P less than 0.05). All the uraemic patients had normal levels of IgG, IgA and IgM in the serum, but elevated levels of IgG3 prior to immunisation. The mechanisms responsible for the asymmetric depression of antibody responses in uraemia are unclear and may account in part for the increased susceptibility to infection in these patients.

Vancomycin and ceftazidime in the treatment of CAPD peritonitis

102 episodes of continuous ambulatory peritoneal dialysis (CAPD) peritonitis were studied prospectively during a 288-day period at The Queen Elizabeth Hospital, Birmingham. Organisms were isolated from 76% of the episodes, with coagulase-negative staphylococci, being the most commonly encountered organism (55%). Initial treatment consisted of intraperitoneal vancomycin and ceftazidime with subsequent adjustment on the basis of antibiotic sensitivities. With this regimen, 83% of the positive cultures became negative by 72 h, 9.8% of cases relapsed and removal of the CAPD catheter was necessary in 8 patients (7.8%). Overall, 92% of cases were cured. No adverse drug reactions were seen. This combination of antibiotics appears effective and safe in the treatment of CAPD peritonitis.

Hypogammaglobulinaemia in nephrotic rats is attributable to hypercatabolism of IgG

The effect of the nephrotic syndrome induced by puromycin aminonucleoside (PA) in rats on specific antibody responses to 2,4 dinitrophenyl (DNP) conjugated to either spider crab haemocyanin (MSH), a T cell-dependent antigen, or hydroxyethyl starch (HES), a T cell-independent type 2 antigen were studied. The serum IgG anti-DNP levels following immunization with both antigens were reduced in nephrotic animals compared with controls while IgM anti-DNP antibody titres were higher. The half-life of IgG anti-DNP antibodies passively transferred into non-immunized nephrotic rats was markedly reduced while the half-life of anti-DNP antibodies of the IgM class was comparable to that in controls. Low serum IgG and elevated IgM levels were seen in nephrotic animals compared to controls. Antibody-forming cells specific for DNP were demonstrated by immunohistology on rat spleens and the numbers of both IgG and IgM-producing cells were found to be significantly increased (P less than 0.05) in nephrotic animals in response to both DNP-HES and DNP-MSH. These data indicate that in nephrotic rats the alteration seen in the serum immunoglobulin levels is not attributable to reduced antibody production but increased catabolism of serum IgG antibodies.

Does cyclosporin A adversely affect Pneumocystis carinii infection?

Fourteen immunosuppressed patients with Pneumocystis carinii infection presented in two clusters that were separated by 2 years. The diagnosis in all cases was made early by alveolar lavage with cytology. The first group of seven patients was immunosuppressed with cyclophosphamide or azathioprine and prednisolone. All recovered with high dose co-trimoxazole. The second group of seven patients was on prednisolone and cyclosporin A. Despite identical treatment three patients died and a further two who survived lost their grafts from rejection. Our data suggest that cyclosporin A adversely affects the prognosis from Pneumocystis carinii infection and raises the question of prophylactic co-trimoxazole in these patients. The clustering of Pneumocystis carinii infection suggests the possibility of nosocomial transmission although in this study we were unable to implicate person-to-person spread of infection.

The role of superoxide anion and hydrogen peroxide in glomerular injury induced by puromycin aminonucleoside in rats

1. The nephrotic syndrome was induced in inbred female Wistar rats by the intravenous injection of puromycin aminonucleoside (PA) (5 mg/100 g body weight). 2. One group (n = 12) received superoxide dismutase (SOD) (15 mg/kg body weight), a second group (n = 12) received polyethylene glycol coupled catalase (PEG-catalase) (5000 i.u./kg body weight) and the third (n = 9) saline (150 mmol/l NaCl) via the intraperitoneal route, in addition to the PA. 3. SOD and PEG-catalase reduced the 24 h urine protein on days 8 and 15 compared with unmodified puromycin treated animals and this difference was significant on day 15 for SOD (P less than 0.05) and for PEG-catalase (P less than 0.01). Glomerular filtration rate, as measured by the creatinine clearance, was lower in the PEG-catalase group but did not differ significantly from the saline treated group. 4. These data suggest that superoxide anion and hydrogen peroxide, or their reaction products, are involved in the glomerular injury of puromycin nephropathy.

Amyloidosis in continuous ambulatory peritoneal dialysis

We report a 53 year old man with chronic renal failure on continuous ambulatory peritoneal dialysis. Following eight episodes of severe peritonitis over a 2 year period, he died and was found to have widespread AA amyloid at post-mortem.

Rheumatoid arthritis and IgA nephropathy

We describe four patients with seropositive rheumatoid arthritis who developed proteinuria and microscopic haematuria. Renal biopsy demonstrated a mesangial proliferative glomerulonephritis with mesangial deposits of IgA. These data suggest a possible causal relationship between rheumatoid arthritis and IgA nephropathy.

The glomerular tip lesion: a steroid responsive nephrotic syndrome

The glomerular tip nephropathy is a cause of the nephrotic syndrome and has distinct pathological features. Glomerular tufts appear normal on light microscopy except for a segmental lesion invariably present in all glomeruli at the origin of the proximal tubule. Data on twenty adults whose renal biopsies demonstrated this lesion and who were followed for a mean of 7.4 years are analyzed. Eighteen patients were treated with steroids; ten of these had complete remission of proteinuria and seven a significant reduction of their proteinuria. Ten patients had moderately impaired renal function (serum creatinine greater than 120 mumol/l) at presentation, eight received steroids and achieved a reduction in serum creatinine. The prognosis was good, with no patient developing chronic renal failure requiring dialysis.

Changing pattern of acute renal failure

During the four-year period 1981-1984, 250 patients with severe acute renal failure were treated at one centre. There were seven obstetric cases (2.8 per cent) 118 'surgical' cases (47.2 per cent) and 125 medical cases (50 per cent). This is a different pattern from that seen in the majority of earlier reports. In 60 of the 125 medical patients the aetiology of the acute renal failure could only be determined by renal biopsy. This series suggests that with changing medical practice (particularly the improvement in resuscitation) and an ageing population, the pattern of causes of acute renal failure is altering. It also highlights the value of renal histology as a guide to diagnosis and treatment in patients with unexplained acute renal failure.