THU0492 MAGNETIC RESONANCE IMAGING OF THE SACROILIAC JOINTS IN PATIENTS WITH HYPERMOBILITY: A RETROSPECTIVE COHORT STUDY

Background:

The incidence of inflammatory and structural lesions on magnetic resonance imaging of sacroiliac joints (MRI SIJs) in patients with hypermobility related disorders has not been fully investigated. Hypermobile patients are more susceptible to pelvic instability and biomechanical stress of the SIJs, leading to MRI SIJ changes similar to those occurring in spondyloarthritis (SpA). Patients with hypermobility and suspected SpA pose a unique challenge owing to the high prevalence of back pain in the hypermobility cohort and the absence of spinal restriction on clinical examination.

Objectives:

In this study, we aim to investigate the incidence of MRI SIJ lesions in patients with hypermobility.

Methods:

We performed a retrospective study of all patients with a confirmed diagnosis of hypermobility related disorders (including hypermobility syndrome, hypermobility spectrum disorders and Ehlers-Danlos Syndromes) referred for an MRI lumbar spine and SIJ between 2011 and 2019 to investigate long-standing back pain. MRIs were examined by a musculoskeletal (MSK) radiologist with more than 25 years of experience, who was blinded to the clinical outcome of the patients. MRI SIJs were assessed for the presence of bone marrow oedema, subchondral sclerosis, erosion, fatty change, enthesitis, ankylosis, joint fluid and capsulitis.

Results:

51 patients with confirmed hypermobility related disorders were referred for MRI SIJ and lumbar spine between 2011 and 2019. 3 patients demonstrated clinical features in keeping with a diagnosis of SpA and were excluded from the study. 15/48 (31.3%) of patients with hypermobility and back pain (but no clinical picture of SpA) were found to have inflammatory and/or structural lesions on MRI SIJ. The most frequent lesions were small foci of bone marrow oedema (16.6%) followed by subchondral sclerosis (12.5%) and fatty change (10.4%). The incidence of erosions was 4.2%.

Conclusion:

There is a relatively high incidence of inflammatory and structural lesions on MRI SIJ of patients with hypermobility. The presence of hypermobility should be taken into consideration when interpreting MRI changes in patients with suspected SpA. Further research into long-term outcomes of MRI SIJs in patients with hypermobility and back pain is required to establish the clinical significance of these findings.

Disclosure of Interests: :

Alexis Jones: None declared, Coziana Ciurtin Grant/research support from: Pfizer, Consultant of: Roche, Modern Biosciences, Hanadi Kazkaz: None declared, Margaret Hall-Craggs: None declared

AB1084 A SYSTEMATIC REVIEW OF THE ABILITY OF WHOLE BODY MRI TO ASSESS DISEASE ACTIVITY AND TREATMENT RESPONSE IN INFLAMMATORY ARTHRITIS

Background:

Whole body MRI (WBMRI) is an imaging technique that allows the assessment of the spine and peripheral joints in patients with inflammatory arthritis (IA) in a single examination. Depending on the protocol, it can potentially identify synovitis, enthesitis, spondyloarthritis and chronic structural changes.

Objectives:

To evaluate the performance of WBMRI in patients with IA for detecting inflammation compared with clinical assessments and to show changes in response to treatment.

Methods:

We conducted a systematic search of the electronic databases MEDLINE, EMBASE and Cochrane Library. Two authors selected independently the eligible studies, extracted the predefined data and assessed the quality using the QUADAS2 tool. Studies that reported a)disease activity scores, b)patient or physician reported outcomes or c)results from other imaging tests in IA patients who underwent WBMRI were included.

Results:

Fourteen studies out of 471 met our inclusion criteria. The majority of the studies were performed in Spondyloarthritis [SpA] (n=9), followed by Rheumatoid Arthritis [RA] (n=4) and Psoriatic Arthritis [PsA] patients (n=3). Nine studies provided clinical and MRI outcome measures. There was great heterogeneity in the quality of studies, disease specific outcomes reported and methodology used to compare with MRI findings. One study documented low correlation between 28 swollen/tender joint count and MRI bone marrow oedema (BME)/synovitis in RA patients, whereas another reported that 31% of MRI negative joints (other than hand joints) exhibited tenderness. In PsA, one study demonstrated correlation between 28 swollen joint count and BME (r=0.54,p=0.03). Superiority of WBMRI in the detection of synovitis and enthesitis over clinical examination was documented in two studies with SpA patients. A third study in SpA showed a ranging agreement of 49 to 100% between clinical and WBMRI enthesitis.

Treatment response to biologics was assessed by WBMRI in 7 studies (5 in SpA, 2 in RA). In RA, one study showed numerical (but not statistically significant) reduction of WBMRI joint count at week 16 and 52 of Adalimumab treatment, whereas the reduction was statistically significant for the subset of patients achieving good EULAR response at week 16. The other study demonstrated a reduction in WBMRI synovitis and bone oedema scores after 1 year of anti-TNF or Tocilizumab treatment (median DAS28 score decreased from 5.1 to 2.1). A multicentre open label study reported a reduction in the number of MRI enthesitis lesions, spinal and sacroiliac joint scores at week 48, year 2 and 3 of Etanercept treatment in SpA patients. The mean BASDAI score decreased from 5.4 at baseline to 1.5 at year 2 and 2.2 at year 3. Improvement in WBMRI scores in SpA was also documented in one Adalimumab and one further Etanercept study.

Conclusion:

There was a variable level of correlation between clinical and WBMRI outcome measures across the included studies. The clinical significance of inflammation detected by WBMRI in some studies remains unclear. Many of the devised WBMRI scores appear to decrease after biologic treatment. Further studies are needed to determine the accuracy of WBMRI in detecting inflammation and its potential utility for clinical practice.

Disclosure of Interests:

Varvara Choida: None declared, Anastasia-Vasiliki Madenidou: None declared, Debajit Sen: None declared, Margaret Hall-Craggs: None declared, Coziana Ciurtin Grant/research support from: Pfizer, Consultant of: Roche, Modern Biosciences

P3-07-48: Axillary Imaging with Dynamic MRI Following Subcutaneous Injection of Superparamagnetic Iron Oxide Nanoparticles

Background: Surgical axillary staging with sentinel node biopsy in clinically node negative patients is standard of care in the management of breast cancer. However sentinel node biopsy is associated with morbidity including a 5% risk of lymphoedema. Superparamagnetic iron oxide (SPIO) enhanced axillary MRI is a promising novel imaging modality that could be used to characterize sentinel nodes non-invasively. We evaluated subcutaneous SPIO enhanced axillary MRI for pre-operative axillary imaging.

Material and methods: Patients scheduled for sentinel node biopsy as part of surgical management of early breast cancer were invited to undergo pre-operative axillary MRI. All images were acquired on a 1.5T scanner using a surface coil. The initial 7 scans were acquired on a Siemens Avanto and the later scans on a Achieva MRI scanner (Philips Best, Netherlands). Following a T2-weighted morphological scan, patients were injected with 2ml of SPIO (4ml in the final 3 patients) subcutaneously into the circumareolar margin in the upper outer quadrant of the affected breast. Post injection, a slightly T2*-weighted dynamic scan was performed (gradient echo, TE = 1.53ms, TR=2.9ms, flip angle 7 degrees, 3mm slice thickness). In addition to the dynamic scan, in 16 patients, a T2 mapping sequence was performed at 10minutes and 120 minutes post injection (turbo spin echo, 8 equi-spaced TEs from 10 to 80ms, TR=2136ms, 3mm slices with an in plane resolution of 1.4×1.4mm). Image analysis was undertaken using Osirix (v3.8, 64-bit). Two consultant radiologists experienced at reading breast and axillary MRI reported all scans. Results: A total of 23 patients underwent axillary MRI with subcutaneous SPIO. Of these in 18 patients (78%), uptake of SPIO was seen in sentinel nodes and lymphatic tracts. At least 1 sentinel node was identified in 17 patients (74%). A total of 106 nodes were identified (4.6 ± 1.7 nodes per patient) and of these 40 demonstrated a significant drop in signal intensity following SPIO injection (1.7 ± 1.3 nodes per patient). All 3 involved nodes were seen to contain a metastatic deposit on MRI.

Discussion: Axillary MRI with subcutaneous SPIO injection is a robust method for imaging sentinel nodes. The normal node count of the axillary basin is lower than expected on histology, suggesting that only the larger nodes and those that take up SPIO are visualized on MRI.

Citation Information: Cancer Res 2011;71(24 Suppl):Abstract nr P3-07-48.

Three-dimensional CT analysis to determine acetabular retroversion and the implications for the management of femoro-acetabular impingement

This study examined the relationship between the cross-over sign and the true three-dimensional anatomical version of the acetabulum. We also investigated whether in true retroversion there is excessive femoral head cover anteriorly. Radiographs of 64 hips in patients being investigated for symptoms of femoro-acetabular impingement were analysed and the presence of a cross-over sign was documented. CT scans of the same hips were analysed to determine anatomical version and femoral head cover in relation to the anterior pelvic plane after correcting for pelvic tilt. The sensitivity and specificity of the cross-over sign were 92% and 55%, respectively for identifying true acetabular retroversion. There was no significant difference in total cover between normal and retroverted cases. Anterior and posterior cover were, however, significantly different (p < 0.001 and 0.002). The cross-over sign was found to be sensitive but not specific. The results for femoral head cover suggest that retroversion is characterised by posterior deficiency but increased cover anteriorly.

Analysis of cover of the femoral head in normal and dysplastic hips: new CT-based technique

We present a new CT-based method which measures cover of the femoral head in both normal and dysplastic hips and allows assessment of acetabular inclination and anteversion. A clear topographical image of the head with its covered area is generated. We studied 36 normal and 39 dysplastic hips. In the normal hips the mean cover was 73% (66% to 81%), whereas in the dysplastic group it was 51% (38% to 64%). The significant advantage of this technique is that it allows the measurements to be standardised with reference to a specific anatomical plane. When this is applied to assessing cover in surgery for dysplasia of the hip it gives a clearer understanding of where the corrected hip stands in relation to normal and allows accurate assessment of inclination and anteversion.

Single center experience of a new intensive induction therapy for ewing's family of tumors: feasibility, toxicity, and stem cell mobilization properties

PURPOSE

To examine the feasibility, tolerability, and toxicity of an intensified induction regimen (vincristine, ifosfamide, doxorubicin, and etoposide [VIDE]) in patients with newly diagnosed Ewing's family of tumors (EFT); to assess ability to maintain dose-intensity, and predictability of peripheral-blood stem cell mobilization.

PATIENTS AND METHODS

Thirty patients were treated with vincristine 1.4 mg/m2 (maximum 2 mg) on day 1, doxorubicin 20 mg/m2, ifosfamide 3 g/m2 plus mesna and etoposide 150 mg/m2 on days 1 to 3. Cycles were given every 21 days for up to six cycles.

RESULTS

One-hundred and seventy cycles of VIDE were given. The median treatment interval was 21 days (21 to 42) and nadir count: hemoglobin 8.3 (6.3 to 11.9), neutrophils 0.045 (0.0 to 2.1), and platelets 45 (3 to 343). There were 96 episodes of infection requiring hospitalization (56%). Growth factor support reduced infectious complications by 34%. Etoposide dose was reduced, or omitted, in 24% of cycles. Four patients did not complete six cycles due to unacceptable toxicity and one patient progressed on treatment. Twenty patients underwent peripheral-blood stem cell harvesting, 15 after cycle 3, and five after cycle 4. Median CD34+ yield was 4.6 x 106/kg per patient (1.8 to 14.5). Overall response to treatment, measured in 24 patients, was 88%. Seven of 11 patients undergoing surgery achieved greater than 90% necrosis of tumor (64%).

CONCLUSION

VIDE is an effective induction regimen with substantial but acceptable toxicity that allows predictable mobilization of stem cells. Maintenance of dose-intensity is feasible in the majority of patients. Growth factors play a role in maintaining dose-intensity and reduce infectious complications.

The use of ultrasound imaging to demonstrate reduced movement of the median nerve during wrist flexion in patients with non-specific arm pain

Following clinical screening, we examined movement of the median nerve at the wrist using high-resolution (10-22 MHz) ultrasound in 16 controls and 12 patients with non-specific arm pain (also referred to as repetitive strain injury). Imaging was performed just proximal to the carpal tunnel with the wrist in neutral, 30 degrees of extension and 30 degrees of flexion. In control subjects the position of the median nerve was 4.8 (SE=0.4) mm more radial with the wrist flexed than with the wrist extended. In the twelve arm pain patients the average change was only 1.2 (SE=0.5) mm. It appears that ultrasound imaging may be helpful in diagnosing non-specific arm pain, a condition for which there are no well-defined diagnostic tests at present. The reduced nerve movement seen with ultrasound imaging confirms previous work with magnetic resonance imaging.

Magnetic resonance imaging in the assessment of complex Müllerian anomalies

OBJECTIVE

To evaluate the accuracy of magnetic resonance imaging in assessment of adolescent patients with complex Müllerian anomalies and its contribution towards operative management.

DESIGN

A retrospective review of magnetic resonance imaging and operative findings.

SETTING

A London teaching hospital that is a tertiary referral centre for complex reproductive tract disorders.

SAMPLE

All adolescents referred for assessment of complex Müllerian anomalies, from 1996 to 1999, and undergoing both magnetic resonance imaging and surgical assessment.

METHOD

In the nine suitable patients magnetic resonance imaging and surgical findings were compared and the role of magnetic resonance imaging in determining the route and type of surgery was evaluated.

MAIN OUTCOME MEASURES

Magnetic resonance imaging data on reproductive tract anatomy and surgical findings detailing reproductive tract anatomy.

RESULTS

There was good correlation of magnetic resonance imaging and operative findings in all cases. The best correlation was with uterine structure. In four cases the magnetic resonance imaging findings were essential for the appropriate choice of the surgical approach and type of procedure.

CONCLUSIONS

Magnetic resonance imaging is a valuable tool in the management of this particular complex group of patients.

Reduced movement of median nerve in carpal tunnel during wrist flexion in patients with non-specific arm pain

Magnetic resonance scans on patients with non-specific arm pain (repetitive strain injury) show reduced median-nerve movement in the carpal tunnel, suggesting that this common condition may involve nerve entrapment.

Function of the nasal muscles in normal subjects assessed by dynamic MRI and EMG: its relevance to rhinoplasty surgery

The external nose is generally considered to have a relatively static shape. Movement of the nose and the potential for change of external shape and the internal airway have been assessed by (1) cadaver dissection and (2) dynamic studies during a standardized series of facial expressions in 13 subjects; video recording of the movement of skin markers, electromyography, and moving magnetic resonance images. A standard description of muscle anatomy is presented. The dynamic investigations indicated the following. Video analysis showed the components of muscle action: dilatation, constriction of the nostril, depression of the tip, vertical contraction in the bridge, and elevation of the alar, in different expressions. Electromyography confirmed muscle actions during expression and phonation. Magnetic resonance imaging demonstrated large changes in the external shape of the nose and nasal aperture due to muscle actions. Muscle function should be given greater consideration in aesthetic and cleft rhinoplasty.

Organ-limited autopsies. Obtaining permission for postmortem examination of the urinary tract

OBJECTIVE

To develop a systematic pre- and postmortem program for obtaining permission for autopsies limited to the urinary tract.

DESIGN

Comparison versus historical control of autopsy permission using a new process comprising premortem education, modification of the permission process, and autopsy limited to the urinary tract.

PARTICIPANTS AND SETTING

Patients, family members, and healthcare providers associated with a nursing home.

INTERVENTION

Education of healthcare providers and family members and modification of autopsy consent and performance.

MAIN OUTCOME MEASURE

Permission rate and demographic characteristics of patients and family members giving permission.

RESULTS

Of the 361 patients who died during the study, we received permission for postmortem examination of the urinary tract for 129 (36%). This was substantially better than the autopsy rate in the year prior to the study, 0.6%. A significantly higher permission rate was associated with patients and contact persons of white race, a higher level of education of the contact person, a nonrelative contact person, and two or fewer individuals making the decision.

CONCLUSION

Permission for organ-limited autopsies can be obtained with a systematic approach.

Long-term urethral catheterization increases risk of chronic pyelonephritis and renal inflammation

OBJECTIVE

To determine the prevalences of chronic pyelonephritis and chronic renal inflammation in elderly nursing home patients at the time of death and to assess correlation with urethral catheterization and other putative risk factors.

DESIGN

Prospective assessment of risk factors with the prevalences of chronic pyelonephritis and renal inflammation at autopsy.

SETTING

A 240-bed long-term care facility.

PARTICIPANTS

All residents > or = 65 years old who died and were autopsied during a 2-year period.

MEASUREMENTS

Antemortem assessment of risk factors for renal inflammation, including a search for any urethral catheterization in the person's life. Prospective assessment of urethral catheterization, catheter obstruction, and use of anti-inflammatory medications and urine cultures. Urinary tract pathology was assessed for gross and microscopic evidence of inflammation and urinary tract stones.

RESULTS

The duration of catheterization was significantly associated with increasing prevalence of bacteriuria, polymicrobial bacteriuria, chronic pyelonephritis, and chronic renal inflammation. The prevalence of chronic pyelonephritis at death was 10 percent (5/52) for patients catheterized > 90 days during their last year of life and zero (0/65) when catheterized < or = 90 days (P < 0.02; Fisher's exact test). Chronic pyelonephritis was significantly associated with renal stones and hydronephrosis. The prevalence of chronic renal inflammation without chronic pyelonephritis was significantly greater than that of chronic pyelonephritis: the prevalence was 43 percent (20/47) when catheterized > 90 days and 18 percent (12/65) when < or = 90 days (P < 0.05). Chronic renal inflammation was associated with hydronephrosis, ureteral dilatation, acute pyelonephritis and diastolic hypertension.

CONCLUSION

Chronic pyelonephritis and chronic renal inflammation are associated with long-term catheterization.

Mouse models of short- and long-term foreign body in the urinary bladder: analogies to the bladder segment of urinary catheters

Catheter-associated bacteriuria is the most common infection occurring in hospitals, where urethral catheters are generally in place for a few days, and in nursing homes, where catheters may be in place for months or years. We developed murine models with intrabladder urinary catheters for studying complications of bacteriuria in short- and long-term catheterization. In the short-term model, a catheter segment was inserted transurethrally and lay free within the bladder lumen. Half of the animals expelled segments during a 2-to-7-day period, durations similar to catheterizations in hospitalized patients. For studies of long-term catheter use, the catheter segment was secured within the bladder by a single suture for up to 12 months. Antibiotics administered for 7 days after catheter placement and housing mice in cages with wire screen floors reduced spontaneous bacteriuria to an acceptably low incidence rate of only 7%. Proteus mirabilis bacteriuria of high concentration provoked the same complications that are common in patients with long-term catheters: acute pyelonephritis, chronic renal inflammation, and struvite stone formation. These models allow inoculation of the bacteria of interest and are suitable for studies of short- and long-term foreign body-associated bacteriuria and its complications.

Acute pyelonephritis associated with bacteriuria during long-term catheterization: a prospective clinicopathological study

Bacteriuria is virtually universal in long-term catheterized patients. This blinded autopsy study of 75 aged nursing home patients demonstrated that acute inflammation of the renal parenchyma was present in 38% of patients with a urinary catheter in place at death versus 5% of noncatheterized patients (P = .004). Of a number of clinical and demographic variables studied, only catheterization was significantly related to acute renal inflammation. Acute cystitis was uncommon, but each case was associated with inflammation of at least one kidney. The majority of kidneys showing acute inflammation (21 [68%] of 31) were not accompanied by acute pyelitis. Acute renal inflammation with or without pelvic inflammation is a common finding in nursing home patients dying with urethral catheters in place. This finding provides additional support for the development of alternatives to the indwelling urethral catheter.

Polyarteritis nodosa involving only the main renal arteries

A unique case of accelerated hypertension and acute anuria in a 24-year-old man is presented. Clinically, the patient was found to have obstruction of both main renal arteries caused by extensive bilateral thrombosis. Microscopically, a healing panarteritis involving only the main renal arteries was found. This was associated with acute renal infarction and tubular atrophy in the left kidney. This appears to be an unusual variant of polyarteritis nodosa limited to both main renal arteries.

Acute renal failure, hemolytic anemia, and thrombocytopenia in poststreptococcal glomerulonephritis

We have presented the case of a 13-year-old boy who had an apparent hemolytic-uremic syndrome, with hemolytic anemia, thrombocytopenia, and acute renal failure. Subsequent laboratory investigations indicated poststreptococcal glomerulonephritis as the cause of renal failure. The triad of hemolytic anemia, thrombocytopenia, and renal failure has not been previously reported in a case of proven poststreptococcal glomerulonephritis.

The prognostic value of the eosinophil in acute renal allograft rejection

A case report of marked peripheral blood eosinophilia and eosinophilic infiltration of a rejected renal allograft in a transplant recipient stimulated our review of the clinical course of 132 consecutive renal transplant recipients. A total of 187 acute rejections occurred in 112 patients. Diagnosis was made by renal biopsy in 124 cases. The percentage of eosinophils in the leukocyte differential of patients with irreversible rejection was 5.2 +/- 5.7 (mean +/- SD) versus that seen in patients with reversible rejection, 2.9 +/- 3.5 (P less than .05). The difference in the total eosinophil counts in each group was not statistically significant. Patients with peripheral blood eosinophil percentages greater than or equal to 4% had a 37.9% irreversible rejection rate, whereas those who had less than 4%, had a 22.4% loss rate (P less than .01). Six of seven patients with greater than or equal to 2% eosinophils in the inflammatory infiltrate of their renal allograft lost their kidney, whereas grafts with less than 2% eosinophils had a 36.8% loss rate (P less than .02). We conclude that the increased presence of eosinophils in the peripheral blood and/or renal allograft biopsy specimen is an adverse prognostic factor for acute rejection outcome.

Recurrent sarcoid granulomatous nephritis and reactive tuberculin skin test in a renal transplant recipient

End-stage renal failure developed in a patient with systemic sarcoidosis and granulomatous nephritis. She received a successful cadaveric renal transplant and was doing well for about six years before graft impairment occurred. At that time, her mother was found to have active open pulmonary tuberculosis, and she had a strongly reactive result on tuberculin skin testing. No clinical evidence of tuberculosis or systemic sarcoidosis was noted, but a renal graft biopsy specimen revealed the recurrence of an unusual sarcoid lesion identical to that which had occurred in her native kidney. Her condition responded to high-dose prednisone with improvement in graft function.

Fulminant amebic colitis in a homosexual man

This report describes a case of fulminant amebic colitis leading to perforation and death in a 35-yr-old homosexual man. Although Entamoeba histolytica may be isolated from stool specimens in 20 to 30% of selected homosexual populations, reports of severe or invasive disease are rare. Some workers have suggested that amebae are only passive colonizers of the colon in homosexual men. In our patient, pathological examination confirmed the presence of extensive colitis with penetration of amebae through the bowel wall. Pertinent data concerning pathogenicity of E. histolytica in homosexuals are reviewed and the public health implications of a virulent strain of amebae are discussed.

Effects of cyclosporine on human endothelial cell cultures

Reports of vascular changes in renal biopsies of transplant patients treated with cyclosporine prompted review of our own renal biopsies and examination of human endothelial cell cultures exposed to cyclosporine in vitro. Endothelial cells were isolated from human umbilical cords by collagenase digestion and cultured in Medium 199 with Earle's salts plus 20% pooled human serum in the absence of antibiotics. Cultures exposed to cyclosporine (0, 0.4, 1.0, 5.0, 10.0 micrograms/ml) for 0, 3, 7, 10, and 14 days were subsequently fixed in 2% glutaraldehyde in 0.1 M cacodylate buffer. Vascular thrombosis was seen in renal biopsies of cyclosporine- and azathioprine-treated patients but the incidence was the same in both groups. No change in the morphology of endothelial cell cultures was observed until 7 days when an increase in size and number of cytoplasmic inclusions became apparent in both control and cyclosporine-treated cultures. By electron microscopy, these inclusions were identified as secondary lysosomes. Their number and size increased with the length of time in culture but did not appear to correlate with the concentration of cyclosporine in the medium. No other morphologic change was identified. It is concluded that the appearance of increased numbers of secondary lysosomes in human endothelial cell cultures is a function of culture age as opposed to cyclosporine exposure. Furthermore, the data indicate that small vessel thrombosis is not specific to treatment with cyclosporine.

Liver scintiscanning as a screening test in the detection of alcoholic cirrhosis

Ninety-nine patients with alcohol related problems underwent a liver scintiscan and biopsy. The scan changes were graded and compared with the histological changes found from percutaneous liver biopsy. The overall correlation between scan and biopsy changes was poor. However, scintiscanning was found to be highly sensitive (90%) in detecting cirrhosis and for this reason is useful as a screening test in selecting alcoholic patients for biopsy.

Development of immune complex nephritis during treatment with the calcium channel-blocking agent nifedipine

Following multiple myocardial infarctions, a patient was treated with the calcium channel-blocking agent nifedipine. Within three months he had proteinuria of up to 460 mg/24 hours. Renal biopsy showed an immune complex glomerulonephritis. The presence of microfibrils was associated with the capillary basement membrane and mesangial changes.

Interstitial nephritis, proteinuria, and renal failure caused by nonsteroidal anti-inflammatory drugs. Immunologic characterization of the inflammatory infiltrate

Nine patients with the unusual combination of renal failure, nephrotic-range proteinuria, and biopsy-proved interstitial nephritis are described. Six of these patients had received nonsteroidal anti-inflammatory agents (three fenoprofen, one ibuprofen, one zomepirac, and one tolmetin). The remaining three patients had no history of exposure to drugs known to cause interstitial nephritis. Immunologic characterization of the infiltrating cells with monoclonal antibodies showed that the majority of cells in most cases were cytotoxic T cells, although some B cells were present in all cases. Giant collecting duct cells were seen in half the patients with drug exposure but in none of the others. Otherwise, there were no conspicuous morphologic differences between patients with and without drug exposure. Many of the patients had associated glomerular abnormalities. Only the zomepirac and tolmetin recipients showed pure interstitial disease. The three fenoprofen recipients and the zomepirac and tolmetin recipients regained normal renal function after the drug was discontinued. The combination of renal failure, nephrotic range proteinuria, and interstitial nephritis is one form of nephrotoxicity observed in patients treated with nonsteroidal anti-inflammatory agents. However, this lesion, which may be mediated by cytotoxic T cells, may also be seen rarely in patients with no apparent drug exposure.

Biochemical and morphological studies on human kidneys preserved for transplantation

Seven human kidneys that had been preserved for transplantation by pulsatile perfusion were studied to correlate the biochemical data with morphologic changes. Metabolite concentrations in mumol/g wet tissue were ATP = 0.26; ADP = 0.34; AMP = 0.45; lactate = 15.21; pyruvate = 0.23; 3-phosphoglycerate = 0.05; fructose-1,6-bisphosphate = 0.06; and hexose-6-phosphate = 0.03. Enzyme activities in mumol/min . mg protein found in the microsomal fraction were alkaline phosphatase = 0.049 and gamma-glutamyl transpeptidase = 0.844. Morphologically, none of the kidneys showed irreversible cell injury in the renal tubules, but some glomeruli showed areas where the endothelial cells appeared stripped off of the capillary basement membranes, indicating possible perfusion injury. The data suggest that it is the resynthesizing ability, as opposed to the absolute concentration of ATP, which determines the recovery and the subsequent viability of the tissue.

Acute renal failure and renal tubular squamous metaplasia following treatment with streptozotocin

Nephrotoxicity, in the form of transient proteinuria, azotemia, abnormalities of tubular function, and acute renal failure, is the major toxic condition following administration of streptozotocin. The renal morphologic and ultrastructural abnormalities associated with streptozotocin remain poorly defined. We describe a patient with metastatic islet cell tumor of the pancreas who was treated with 16 weekly courses of 1 g/m2 of streptozotocin without marked change in renal function. Following a six-week hiatus without change in renal function, a single course of 1 g/m2 of streptozotocin was administered and resulted in acute renal failure. Light microscopic examination of the kidneys showed irregularly dilated renal tubules lined by low cuboid epithelium. The cells were pleomorphic and showed some mitoses. Nuclei were irregular and variably hyperchromatic. Electron microscopic examination disclosed large aggregates of fine microfilaments in the proximal convoluted tubules and collecting ducts. Microfilament aggregates were both free in the cytoplasm and membrane bound. Microfilaments were proved to be tonofilaments by the demonstration of keratin within the epithelium, using the immunoperoxidase method. These data suggest that squamous metaplasia may be an important part of streptozotocin renal toxicity, and the suggestion is made that they may be an antecedent of neoplastic change.

Basaloid tumor of the sigmoid colon

A second case of basaloid carcinoma arising in the midsigmoid colon is reported. By light microscopy the tumor was seen to be composed of islands of small, poorly differentiated cells separated by cellular connective tissue. Also seen were small foci of keratinized cells, Ultrastructure study confirms the largely basal character of the tumor and also shows some cells containing tonofilament bundles, representing a more squamoid differentiation. The similarity of this tumor to basaloid tumors arising in the transitional epithelium of the anal canal is discussed, and the suggestion that the tumor arises from a pluripotential basal cell is made.

Oat cell carcinoma of larynx

Mucus secretion, cytoplasmic argyrophilia, intracellular lumen, neurosecretory granules, and tonofilaments were observed in a histologic and ultrastructural study of laryngeal oat cell carcinoma. In theories of tumor genesis, more than one line of cellular differentiation is a significant finding.

Carcinosarcoma of the uterine cervix: a light and electron microscopic study

A case of carcinosarcoma of the uterine cervix is presented. Light microscopic and ultrastructural features of the tumor are described. While the epithelial component had the appearance of a carcinoma arising from endocervical epithelium, the stromal component was composed of malignant smooth muscle cells together with some cells having the charactristics of malignant fibroblasts. The tumor is considered to arise from the müllerian tract mesoderm and to be part of the spectrum of tumors which range from the totally benign adenofibroma to the malignant heterologous mixed mesodermal tumor.

Transformation of diffuse proliferative glomerulonephritis to membranous nephritis in a patient with systemic lupus erythematosus

Transformation of diffuse proliferative glomerulonephritis to membranous nephropathy 10 years later, in a patient with systemic lupus erythematosus, is reported. The original biopsy showed diffuse proliferative glomerulonephritis with epithelial crescent formation, 'wire loop' thickening of the capillary walls and moderately severe interstitial inflammation. Electron microscopy showed large subendothelial electron-dense deposits. Following treatment with a combination of prednisone and azathioprine for 2 years the 24-hour urine protein decreased from 8.8 g to 300 mg. In September, 1979, she again developed facial and pedal edema. With the exception of proteinuria of 6.0 g/24 h, the renal function remained normal. Repeat renal biopsy showed membranous glomerulopathy. On electron microscopy, electron-dense deposits were predominantly in a subepithelial position. The significance of the original biopsy as a predictor of eventual outcome and of sequential biopsies to the clinical management of patients with systemic lupus erythematosus is discussed.

Surreptitious habitual vomiting simulating Bartter's syndrome

A patient with hypokalemic alkalosis, normotensive hyperreninism, hyperaldosteronism, increased levels of urinary and plasma prostaglandin E, and vascular hyporesponsivity to angiotensin II was thought to have Bartter's syndrome. Results of a kidney biopsy showed hyperplasia of the juxtaglomerular apparatus but no renomedullary cell hyperplasia. A 24-hour urine collection showed a low chloride level and no increase in the fractional chloride clearance, thus excluding Bartter's syndrome. Subsequent disclosure of surreptitious, habitual vomiting explained the hypokalemia.

Structural changes following hypothermic preservation of human cadaveric kidneys

Three kidneys preserved as though for transplantation became available for study. The clinical details relating to the donors and methods of preservation by simple hypothermia and pulsatile perfusion are presented. Light microscopic and ultrastructural features observed following perfusion fixation of the kidneys are described. All three kidneys showed some reversible ischemic cell damage, but only one showed evidence of ischemic cell damage that was considered to be irreversible. The latter was seen focally in the pars recta of the proximal convoluted tubules and in the ascending thick limb of the loop of Henle. The irreversible changes were present in the kidney that had undergone the longest period of simple hypothermic storage prior to transfer to pulsatile perfusion preservation. The similarity of the findings to those seen in vivo in the rat after one hour of total renal ischemia, followed by 24 hours' reflow, is discussed; a hypothesis is suggested to explain the site of the irreversible injury seen in the kidneys under study.

Unusual ultrastructural features in a case of acute diffuse proliferative glomerulonephritis

A case consistent with recurrent acute poststreptococcal glomerulonephritis but with atypical features is described. Light microscopy revealed a diffuse proliferative glomerulonephritis. A spectrum of ultrastructural features, from the typical "humpy bumpy" subepithelial deposits to the apparent disappearance of the deposits within the epithelial cells, is presented. An unusual piling up of basement membrane material around the deposits is described, together with some areas showing an appearance reminiscent of membranous glomerulopathy. Resorption of the dense deposits within epithelial cells is suggested and a hypothesis advanced that the basement membrane reaction may indicate an incipient chronic immune complex lesion.

Amyloid deposition in a renal allograft in a case of amyloidosis secondary to rheumatoid arthritis

A case of amyloidosis secondary to rheumatoid arthritis is presented in which renal transplantation was performed. Five years after transplantation the patient died following an episode of acute pancreatitis. During the intervening period the rheumatoid arthritis was considered quiescent, but his course was marked by several infectious processes caused by unusual organisms. The allograft function remained normal. Apart from renal amyloid the autopsy showed extensive generalized amyloidosis, most marked in vessel walls and endocrine organs. Amyloid deposits were located exclusively in the vessel walls of the transplanted kidney.