Nebulized voriconazole in infections with Scedosporium apiospermum--case report and review of the literature

Scedosporium infections are rare complications in immunocompromised patients or patients with chronic pulmonary disease. While Scedosporium prolificans is resistant to most antimycotics, Scedosporium apiospermum is usually sensitive to voriconazole and posaconazole. Pharmacokinetics and efficacy of nebulized voriconazole have been described in a murine model previously. We report for the first time the safe and effective use of nebulized voriconazole for the treatment of severe pulmonary infection with Scedosporium apiospermum in an adolescent with cystic fibrosis.

Refractory focal epilepsy in a patient with methylmalonic aciduria: case report on positive and long-lasting effect of rufinamide

We report on a 5-year-old boy with methylmalonic aciduria, an autosomal recessive inborn error of metabolism leading to accumulation of methylmalonic-CoA and thereby causing intoxication with leading symptoms of hyperammonaemia and metabolic acidosis. Hyperammonemia itself causes brain oedema. In our patient, this led to a vast metabolic stroke of the left hemisphere and subsequent pharmacoresistant epilepsy. Guided by his main seizures--drop attacks--the orphan drug rufinamide (RUF) was introduced as "off-label use" and led to freedom of drop attacks and tonic-clonic seizures over a period of 14 months as well as normalisation of the electroencephalogramm. Only once during an episode of fever and diarrhoea with reduced level of RUF did some provoked seizures with focal complex semiology for the time period of infection occur. In the 16 months follow-up, the patient also improved in his development, showing a more stable gait with the hemiparesis and understanding more complex sentences.

[Pancytopenia, fever, and splenomegaly in a 2-year-old boy]

HISTORY

Suspected of having a systemic malignancy a 22-month-old boy was admitted to hospital with fever, pancytopenia and hepatosplenomegaly. The boy was of ethnically German origin and no travel abroad was reported.

DIAGNOSIS

Intensive search for a focus of infection, laboratory tests and bone marrow microscopy failed to be diagnostic. Serological findings and detection of Leishmania DNA in bone marrow by polymerase chain reaction (PCR) led to the diagnosis of visceral leishmaniasis. On explicit questioning the child's parents reported a stay in Greece 18 months before onset of symptoms.

TREATMENT AND COURSE

On the fourth day of i.v. therapy with liposomal amphotericin B, 3mg/kg/d for 10 days, the fever subsided. Platelets and leukocytes regained normal levels. The child was discharged after 10 days of treatment and received two more doses on days 14 and 21.

CONCLUSION

Negative results on microscopic bone marrow inspection do not rule out visceral leishmaniasis. Detection of anti-Leishmania antibodies may support the suspected diagnosis and provide the indication for PCR technique.

MEDIANOVO - a media database for medical education, research and health care

MEDIANOVO provides a high quality, scientifically indexed multi-media database with comfortable authoring and download functions through a web-based frontend. Currently, MEDIANOVO is used by medical teachers as a repository for storing and sharing media for educational purposes. However a database was created which could also serve with training and further education, in computer based learning systems as well as medical publishers and for individual patient information. Through the web-frontend the content is available worldwide.

[Pulmonary nodular amyloidosis mimicking multiple pulmonary metastases of carcinoma of the corpus uteri]

INTRODUCTION

Pulmonary nodular amyloidosis (PNA) is a phenomenon that is rarely diagnosed anywhere in the world.

METHODS

We report a case of a 63-year-old woman who smoked in whom a chest X-ray examination 5 years after diagnosis and radical treatment of a highly differentiated carcinoma of the corpus uteri showed multiple lung metastasis. To elucidate these findings by bronchoscopy and thoracoscopy we took a specimen from the right pleura and from one of the suspicious nodules, which were up to 3 cm in diameter; we also obtained some of the bronchial secretion.

RESULTS

The nodules were histopathologically diagnosed as PNA.

CONCLUSION

Even if it is rare, PNA also belongs in the differential diagnosis of metastatic cancers. For us evidence of Pseudomonas fluorescens in the sputum is a reason for discussing a chronic, clinical unobtrusive local inflammation with hyperactivity of the B-cells as the hypothetical etiology of the amyloidomas.

Carotenoid supply in breast-fed and formula-fed neonates

Carotenoids have various biological functions including their role as antioxidants. For humans fruits and vegetables are the only source of carotenoids. In the first months breast milk and/or formula preparations are the only nutrition for infants. To study the influence of nutrition on the plasma carotenoid profile in newborns, breast milk, different formula preparations, and the plasma of breast-fed (BF) and formula-fed (FF) newborns were analyzed by high-performance liquid chromatography. The method used allowed beta-carotene, alpha-carotene, lycopene, and beta-cryptoxanthine to be detected and all four were found in breast milk. In colostrum carotenoids were up to five times higher than in mature breast milk (P<0.05). In contrast, not all carotenoids could be found in formula preparations. Beta-carotene was detected in four out of eight, and beta-cryptoxanthine in three out of eight formula preparations. Lycopene and alpha-carotene were not detectable in any of the formula preparations. Four formula preparations did not contain any carotenoids. FF infants had different plasma carotenoid profiles compared to BF infants. beta-carotene was significantly lower in FF infants [14 (0-32) microg/l, median and interquartile ranges] than in infants after birth [24 (19-310) microg/l, P<0.05], and BF infants [32 (22-63) microg/l, P<0.05]. While newborns after birth had measurable plasma concentrations of lycopene (16 [14-18] microg/l) and of alpha-carotene [5 (0-8) microg/l), these carotenoids were no longer detectable in FF infants after day 14.

CONCLUSION

FF and BF infants show significant biochemical differences in plasma carotenoid concentrations.

Transmission dynamics of tuberculosis in a high-incidence country: prospective analysis by PCR DNA fingerprinting

We have prospectively analyzed the DNA fingerprints of Mycobacterium tuberculosis strains from a random sample of patients with newly diagnosed tuberculosis in Windhoek, Namibia. Strains from 263 smear-positive patients in whom tuberculosis was diagnosed during 1 year were evaluated, and the results were correlated with selected epidemiological and clinical data. A total of 163 different IS6110 fingerprint patterns were observed among the 263 isolates. Isolates from a high percentage of patients (47%) were found in 29 separate clusters, with a cluster defined as isolates with 100% matching patterns. The largest cluster included isolates from 39 patients. One predominant strain of M. tuberculosis caused 15% of cases of smear-positive pulmonary tuberculosis in Windhoek. That strain was also prevalent in the north of the country, suggesting that in contrast to other African countries with isolates with high levels of diversity in their DNA fingerprint patterns, only a restricted number of different strains significantly contribute to the tuberculosis problem in Namibia.

Effects of dietary supplementation of saturated fatty acids and of n-6 or n-3 polyunsaturated fatty acids on plasma and red blood cell membrane phospholipids and deformability in weanling guinea pigs

The fatty acid composition of plasma cholesteryl esters, plasma phospholipids, red blood cell (RBC) membrane phosphatidylcholine (corresponding to the outer membrane leaflet), and phosphatidylethanolamine (corresponding to the inner membrane leaflet) was investigated in weanling guinea pigs fed with diets of cacao (saturated fatty acids), sunflower oil [n-6 polyunsaturated fatty acids (PUFA)] or fish oil (n-3 PUFA) for 20 wk. RBC deformation was measured by means of a cell-transit analyzer (filtration) and a cone-plate rheoscope. The contents of saturated fatty acids in plasma phospholipids and RBC membrane leaflets were similar in all three groups. Diets with sunflower oil resulted in a high content of linoleic acid in plasma cholesteryl esters and in the outer leaflet of RBC membranes. Fatty acids of fish oil were mainly incorporated in plasma phospholipids and in the inner leaflet of RBC membranes. The arachidonic acid content was high in all groups in the plasma phospholipids and in the inner leaflet. The n-6 and n-3 PUFA were mainly incorporated in the inner leaflet. In all groups the polyunsaturated/saturated fatty acid ratio and the total PUFA content were similar in the inner RBC membrane. The RBC filtration times and the RBC deformation indices were not affected by the dietary treatment.

Childhood tuberculosis in Germany between 1985 and 1994: comparison of three selected patient groups

SETTING

Clinical and epidemiologic features of childhood tuberculosis in Germany are unknown for recent years. The characteristics of patient groups may show typical differences, depending on the source of data.

OBJECTIVE

To identify typical features of childhood tuberculosis in Germany, and to relate the characteristics of patient groups to the purpose of the reporting centres.

DESIGN

Comparative, retrospective, descriptive analysis of clinical and notification records by standardized data sheet. Evaluation of cases of active tuberculosis in children recorded between 1985 and 1994 at three study centres.

RESULTS

One clinical study centre was a referral centre for sick children with an unclear diagnosis, the second specialized in tuberculosis, and the third was a public health office. Almost two thirds (64%) of the 285 evaluated patients were four years of age and under. Between 73% and 96% of children suffered from pulmonary disease and 17% to 58% were culture positive (range between study centres). Source cases had been found for 23% to 52% of children, and the primary reason for clinical evaluation was a positive tuberculin test for between 12% and 57%. Foreign-born children showed characteristic differences.

CONCLUSION

The characteristics of reported childhood tuberculosis differ depending on the reporting centre. A significant number of notified cases were probably wrongly diagnosed.

Long-chain polyunsaturated fatty acids in plasma and erythrocyte membrane lipids of children with phenylketonuria after controlled linoleic acid intake

It has been reported that children with classical phenylketonuria (PKU) have reduced levels of arachidonic acid (AA, 20:4 n-6) and docosahexaenoic acid (DHA, 22:6 n-3) in plasma and membrane phospholipids compared to controls and may therefore require supplementation. However, it is not established that these changes are specific for PKU. They may as well be attributed to the specific composition of a largely vegetarian diet used for dietary PKU treatment. We therefore investigated the fatty acid composition of plasma phospholipids (PL), plasma cholesterol esters (CE), red blood cell phosphatidylcholine (PC), and red blood cell phosphatidylethanolamine (PE) in two groups of PKU patients including 8 children between 1 and 6 years (group A), 9 adolescents between 11 and 18 years (group B), and 20 age-matched healthy controls. Group A had good dietary control (median plasma phenylalanine 272 mumol/L during the last 6 months before phospholipid analysis) while median phenylalanine in group B was 714 mumol/L (p < 0.001). When compared to age-matched controls, group A showed significantly lower DHA levels in PE (4.21 vs 5.85 weight% (wt%), p < 0.01), in PC (1.02 vs 1.25 wt%, p < 0.05) and in CE (0.25 vs 0.54 wt%, p < 0.05). There was no significant difference of DHA between group B and controls. AA levels were similar in phospholipids of all groups. We conclude that reduced levels of long-chain polyunsaturated fatty acids in PKU patients occur only in those patients with strict dietary therapy with respect to n-3 fatty acids, most probably caused by reduced intake of n-3 fatty acids.

The clinical manifestation of the kwashiorkor syndrome is related to increased lipid peroxidation

Along with the onset of severe kwashiorkor symptoms, a 20-month-old child showed biochemical signs of markedly increased lipid peroxidation, with a decrease of plasma antioxidants and decreased proportions of polyunsaturated fatty acids in plasma and red cell phospholipids. Additionally, plasma concentrations of the lipid peroxidation products malondialdehyde and hexanal, as well as the urinary excretion of leukotriene E4, were found to be increased. All biochemical alterations normalized along with subsequent clinical improvement. These findings suggest that the extent of lipid peroxidation is strongly related to the severity of the kwashiorkor syndrome.

High incidence of epilepsy related to onchocerciasis in West Uganda

The incidence of epilepsy was assessed in an onchocerciasis endemic area in West Uganda over a period of 4 years. A high overall crude incidence rate of 215 per 100000 person-years was found (age-adjusted: 156 per 100000 person-years) and the incidence in zones of high onchocerciasis endemicity was significantly higher than in low endemic zones (age adjusted rates: 232 per 100000 person-years versus 77 per 100000 person-years; Yates corrected chi2: P < 0.01). The data constitute a baseline for an ongoing intervention study on the effects of onchocerciasis control on epilepsy incidence in the study area. If a causal relationship between onchocerciasis and epilepsy can be confirmed, this would have significant implications for the concept of morbidity due to onchocerciasis and for the prevention of epilepsy in the endemic areas.

Childhood tuberculosis: an index measuring the ability to detect cases early

SETTING

Tuberculosis control programmes are conventionally monitored using data from sputum smear positive adult patients. Good overall results may mask significant and avoidable shortcomings with tuberculosis control in children.

OBJECTIVE

To develop a specific surveillance tool for child patients, using the ability to detect cases early as a parameter for the impact of control measures.

DESIGN

A simple index of early detection was compiled with values ranging from 0 to 100. Three groups of tuberculous children diagnosed in Germany between 1985 and 1994 (n = 303), and five other groups from the literature, were used to make a preliminary assessment of the validity of the index.

RESULTS

The index values of 10, 13 and 24 for the German groups correlate well with other analysed patient data and the different functions of the institutions where the patients were diagnosed. Comparable characteristics could be found when applying the index to published data of other cases, with values of between 12 and 74.

CONCLUSION

The proposed index seems suitable for monitoring early detection of child cases. Unexpected trends can be disclosed or effects of changed programme activities assessed. Routine use of the index would help the health services focus their attention on problem areas and specific patient groups with extremely low or falling index values. Conclusions can be drawn regarding the overall impact of the control programme.

Influence of n-6 and n-3 polyunsaturated fatty acids on the resistance to experimental tuberculosis

It has previously been shown that the n-3 polyunsaturated fatty acids (PUFAs) eicosapentaenoic acid (20:5(n-3)) and docosahexaenoic acid (22:6(n-3)) possess antiinflammatory properties and can interfere with immune functions. To evaluate whether this would affect resistance to infection, we studied the influence of different types of fatty acids (FAs) on experimental tuberculosis in an animal model. Three groups of 26 weanling guinea pigs were fed isocaloric diets with 26 cal% fat that differed in FA composition with respect to saturated FAs, linoleic acid (18:2(n-6)), eicosapentaenoic acid (20:5(n-3)), and docosanexaenoic acid (22:6(n-3)) as follows: (1) reference (REF) group: 14.8 cal% saturated FAs and 2.8 cal% linoleic acid; (2) n-6 group: 4.6 cal% saturated FAs and 15.4 cal% linoleic acid; (3) n-3 group: 6.3 cal% saturated FAs, 10 cal% linoleic acid, 1.4 cal% eicosapentaenoic acid, and 0.9 cal% docosahexaenoic acid. After 13 weeks, 18 animals from each group were intramuscularly injected with 180 colony-forming units (CFU) Mycobacterium tuberculosis strain H37Rv. Eight noninfected animals per group served as controls. Seven weeks later, the mean number of mycobacteria recovered from the spleens of the n-3 group (log 4.34 CFU, standard error of the mean [SEM], 0.12) was significantly higher than from the REF group (log 3.90 CFU; SEM, 0.15) and the n-8 group (log 3.93 CFU; SEM, 0.13; P < .05). In addition, the Root Index of Virulence (RIV) showed the most pronounced progression of the disease in the n-3 group. The mean size of the tuberculin reaction was larger in the n-3 group than in the other groups (P < .05). There was no significant difference between the n-6 group and the REF group. We conclude that supplementing the diet with n-3 FAs eicosapentaenoic acid and docosahexaenoic acid can affect resistance to M tuberculosis, whereas supplementing with n-6 FAs does not.

Plasma carotenoids in German children and adolescents

Carotenoids are important antioxidants and precursors of vitamin A, but only few studies have been carried out on plasma carotenoid levels in paediatric age groups. Using high-performance liquid chromatography we analysed concentrations of four important carotenoids (alpha-carotene, beta-carotene, cryptoxanthin, lycopene) in 129 healthy German children and adolescents (81 boys, 48 girls; age 1-18 years). For all carotenoids analysed, no significant differences between girls and boys were found. alpha-Carotene values ranged from 0 mumol/l (below detection limits) to 0.73 mumol/l (0-395 micrograms/l), beta-carotene from 0.09 mumol/l to 2.68 mumol/l (48-1443 micrograms/l), lycopene from 0 mumol/l to 1.51 mumol/l (0-815 micrograms/l), and cryptoxanthin from 0 mumol/l to 0.30 mumol/l (0-164 micrograms/l), respectively. Data analyses according to age groups showed a tendency towards higher levels of alpha- and beta-carotene, and lower levels of lycopene in young children. These differences were significant when children younger than 4 years were compared with those above 8 and 12 years, respectively. The data presented may serve as reference values for studies on children with nutritional disorders and diseases associated with a risk of vitamin deficiencies.

CONCLUSION

Carotenoids are important antioxidants and singlet oxygen scavengers. Plasma levels of alpha-carotene, beta-carotene, lycopene and cryptoxanthin were determined in 129 healthy German children and adolescents. Highest values were found for beta-carotene and lycopene.

Influence of dialysis on plasma lipid peroxidation products and antioxidant levels

In patients with end-stage renal failure (ESRF), the incidence of atherosclerosis and cancer is increased. The importance of lipid peroxidation (LPO) products in the pathogenesis of these complications has recently been emphasized. The LPO products malondialdehyde (MDA) and hexanal, lipophilic antioxidants and erythrocyte glutathione (GSH) were estimated in 10 pediatric hemodialysis (HD) patients before and after HD and in 11 peritoneal dialysis (CPD) patients. Before HD, MDA was elevated [median (interquartile range): 384.5 (110 to 501) nM; normal < 150 nM], whereas plasma hexanal levels were normal in all patients [130.5 (88 to 222) nM; < 320 nM]. HD decreased MDA concentrations on average by 88% but did not change hexanal levels. CPD patients exhibited high plasma MDA concentrations [371 (287 to 468) nM], whereas hexanal was in the low normal range [56 (51 to 81) nM]. Antioxidants were normal in both groups and unchanged during HD. GSH decreased slightly during HD. We hypothesize that MDA may accumulate in ESRF due to reduced plasma clearance. Our results argue against a general increase of LPO in uremia.

The Nakalanga syndrome in Kabarole District, Western Uganda

An acquired condition resulting in arrested growth was reported in the 1950s and 1960s from along the Nile near Jinja in eastern Uganda. This became known as Nakalanga dwarfism, and an association with onchocerciasis was postulated. After control of onchocerciasis through larvaciding in this area some 30 years ago, no new cases have been noted. We now report this condition from western Uganda where its appearance seems to be a relatively recent event. Thirty-one persons with short stature, 15 years of age and older, were identified through household surveys in an area of Kabarole district with a high prevalence of onchocerciasis. Cases identified were matched with controls selected for age and sex from the nearest household. Cases of Nakalanga syndrome weighed significantly less and were shorter than controls. The Z scores for weight-for-age, weight-for-height, height-for-age, and body mass index were significantly less among cases. Other clinical features observed among cases included absence of secondary sexual characteristics, skeletal deformities, dental caries, and mental retardation. All cases and 22 (79%) controls had microfilariae of Onchocerca volvulus in skin snips. All community members interviewed were aware of the Nakalanga syndrome, and 93% believed it to be acquired sometime after birth. The possible association with onchocerciasis is discussed.

The prevalence of epilepsy follows the distribution of onchocerciasis in a west Ugandan focus

Epidemiological surveys indicate that the prevalence of epilepsy is higher in developing countries than in industrialized countries. Except for neurocystocercosis due to Taenia solium, little is known about possible underlying causes. This article reports the relationship between epilepsy and onchocerciasis in an Onchocerca volvulus endemic area in West Uganda. Individuals complaining of seizures were identified by means of a population census in 12 villages. Active epilepsy was confirmed in 61 of 4743 inhabitants (crude prevalence rate = 1.3%; age-standardized rate = 1.1%). Distribution of epilepsy in the study area was clustered, ranging from a prevalence of 0.2% to 3.4% in different villages. Age-specific prevalence was highest between 10 and 19 years, with a rate of 3.6% for the study are as a whole, and up to 10.0% in villages of high epilepsy prevalence. The prevalence of onchocerciasis in the 10-19-year-old age group was assessed by skin-snip biopsy and ranged from 15% to 85% in different villages. Epilepsy was significantly more frequent in the three villages with the highest levels of O. volvulus endemicity than in other villages (P < 0.0001). Serological testing for T. solium infection was positive in one and borderline in three of 53 epilepsy patients tested. The significant correlation between epilepsy and onchocerciasis did not change when these four patients were excluded from the analysis. These findings suggest a strong association between epilepsy and onchocerciasis in this area. This could have significant implications for the concept of morbidity due to O. volvulus.

(n-6)-Fatty acids in plasma lipids of children with atopic bronchial asthma

It has been suggested that atopy is associated with an impairment in the delta 6-desaturation of (n-6)-polyunsaturated fatty acids and subsequently low levels of eicosanoid precursors. To evaluate this hypothesis we analyzed the fatty acid composition of plasma phospholipids and plasma cholesterol esters in a well-defined group of children with atopic bronchial asthma (n = 17) and age-matched healthy controls (n = 10). Atopic children showed significantly higher levels of linoleic acid and lower proportions of arachidonic acid in plasma lipids. No differences were observed with respect to gamma-linolenic acid (GLA) and dihomo-gamma-linolenic acid (DHLA). It is concluded that there is no biochemical evidence for a delta 6-desaturation defect in atopic children and therefore no justification for the supplementation of GLA and DHLA; e.g., by the use of evening primrose oil preparations.

Fatty acid composition of the milk of well-nourished Sudanese women

The fatty acid (FA) composition of samples of breast milk obtained from well-nourished Sudanese women was determined by capillary gas chromatography. Saturated fatty acids (SFA) constituted 46%, monoenoic acids (MONOENE) 33% and polyunsaturated fatty acids (PUFA) accounted for 21% of total fatty acids. The mean value (18.28%) of the essential fatty acid linoleic acid was comparable to the levels reported for well-nourished mothers from industrialised countries. The proportions of fatty acids synthesised de novo in the mammary gland (10:0, 12:0, 14:0) were less than expected from published studies of mothers consuming low fat diet averaging 17.4%. The amount of 22:6 n-3 which is synthesised from 18:3 n-3 and also taken up by consumption of fish were found to be low. The possible nutritional implications of the low n-3 fatty acids for the infants should therefore be investigated.

Use of BCG in high prevalence areas for HIV

Recommendations state that, where the risk of tuberculosis is high, BCG should be administered to infants as early in life as possible, even if the mother is known to be HIV-infected. BCG should be withheld from individuals with symptomatic HIV infections. However, continuing reports from sub-Saharan Africa and elsewhere of BCG complications in HIV-infected persons call for a re-assessment of current vaccination policies. For HIV-infected infants any benefit of BCG vaccination may be marginal because the prognosis is very poor. It is however not possible to exclude HIV-infected children from BCG vaccination at birth. HIV-uninfected infants born to HIV-infected mothers are at great risk of tuberculosis infection, which justifies routine vaccination. BCG rarely causes serious complications. Theoretically, persons with asymptomatic HIV infection may be at greater risk of complications from BCG vaccines, but available data are inconclusive in that respect. To vaccinate children with BCG at one year of age does not seem feasible and would increase the risk of tuberculosis especially for uninfected infants of HIV seropositive mothers. Available data seem to indicate that routine vaccination of newborns is indeed safe, even in areas with high prevalence of HIV infection.

Polyunsaturated fatty acids in erythrocyte and plasma lipids of children with severe protein-energy malnutrition

The fatty acid composition of plasma cholesterol esters, plasma phospholipids, erythrocyte phosphatidylcholine and erythrocyte phosphatidylethanolamine was investigated in severely malnourished Nigerian children with kwashiorkor (n = 12) and marasmus (n = 32). Normally nourished children from the same area (n = 23) served as controls. The malnourished children showed a significant reduction of highly polyunsaturated fatty acids in cholesterol esters, phospholipids and phosphatidylcholine. No differences between the groups were found in erythrocyte phosphatidylethanolamine. Children with kwashiorkor had lower levels of linoleic acid metabolites and docosahexaenoic acid than marasmic children. The results suggest that the kwashiorkor syndrome is associated with impaired desaturation and elongation of PUFA and/or increased lipid peroxidation.

Glutathione and association antioxidant systems in protein energy malnutrition: results of a study in Nigeria

Marasmus and kwashiorkor are manifestations of protein energy malnutrition. The pathophysiology of these disorders is poorly understood. We studied a number of blood antioxidants [glucose-6-phosphate dehydrogenase (G6PDH), glutathione reductase (GR) and its cofactor flavin adenine dinucleotide (FAD), the tripeptide glutathione as the major nonprotein thiol], serum albumin, and retinol-binding protein in 12 children suffering from kwashiorkor with all classical symptoms, in 13 patients with clinically severe marasmus, in 19 marasmic but active children, and in 23 controls. Significant changes were observed for erythrocyte glutathione and correspondingly for nonprotein thiols in whole blood (0.72 +/- 0.29 mM thiols in controls, 0.50 +/- 0.22 mM in marasmus, 0.35 +/- 0.23 mM in severe marasmus, and 0.22 +/- 0.13 mM in kwashiorkor). These differences were paralleled by a decrease in serum albumin concentration so that the molar ratio of nonprotein thiols/albumin had an average value of approximately 1.5 in all groups. The erythrocyte glutathione-reducing system, represented by G6PDH and glutathione reductase, showed only slight differences among the four groups of children; the supposition that kwashiorkor occurs predominantly in children with aberrant G6PDH could not be substantiated. Unexpectedly, erythrocyte FAD, an index of riboflavin status, was normal in most malnourished patients. Discussed is the prospect of administering glutathione in kwashiorkor patients.

Evaluation of ultrasonography for the detection of drug-induced changes in onchocercal nodules

Clinical trials of macrofilaricidal drugs against Onchocerca volvulus are impeded due to the lack of means for assessing in vivo drug-induced changes in the onchocercomas. The application of ultrasonography in the sequential monitoring of morphologic alterations of onchocercal nodules after six weeks of suramin therapy was evaluated in 20 male patients from Ghana with a total of 64 nodule sites. After each follow-up session, a number of onchocercal nodules were extirpated so that by the end of one year, all nodules had been removed for histologic examination. The sonomorphologic changes observed and their time of appearance correlated well with the histologic findings of the onchocercomas. Eighty-three percent of the onchocercal nodules became hyperechogenic and 22% developed echo-free areas at the end of the follow-up period. Absence of the lateral acoustic shadow increased by more than 30% and the lack of differentiation of the worm center from the capsule and the nodule from its surrounding tissue increased by the end of one-year posttreatment to 100% and 91%, respectively. A mean reduction of nodule size of 27% was also documented. The histologic studies revealed that the proportion of the dead female worms increased from 17% at the end of the suramin therapy to 48% six months later and reached 61% at one year. It is concluded that ultrasonographic monitoring of onchocercomas can provide essential information on drug effects and facilitate clinical trials of macrofilaricidal drugs, limiting histologic evaluation to a few objectively selected onchocercomas.

Influence of dietary (n-3)-polyunsaturated fatty acids on leukotriene B4 and prostaglandin E2 synthesis and course of experimental tuberculosis in guinea pigs

In the present study eicosanoid synthesis was studied in macrophages of guinea pigs fed different amounts of (n-6)- and (n-3)-polyunsaturated fatty acids (PUFA). Three groups of weanling guinea pigs were fed by isocaloric diets differing only in their contents of PUFA: controls with 2.8 Cal% of linoleic acid (LA; 18:2(n-6)); (n-6)-rich fed animals with 15.4 Cal% of LA; and (n-3)-rich fed animals with 10.1 Cal% of LA, 1.4 Cal% of eicosapentaenoic acid (20:5(n-3)) and docosahexaenoic acid (22:6(n-3)). After 13 weeks half the number of animals from each group was infected i.m. by 180 colony forming units of Mycobacterium tuberculosis strain H37Rv. Seven weeks after infection the release of leukotriene (LT)B4 and prostaglandin (PG)E2 was quantified in calcium ionophore stimulated whole blood, peritoneal macrophage cultures and alveolar macrophages by immunoassays after high performance liquid chromatography. Synthesis of LTB4 and PGE2 was found to be reduced in (n-3)-rich fed guinea pigs (p < 0.05), and equivalent between controls and (n-6)-rich fed animals. Controls and (n-6)-rich fed animals showed the same mycobacterial counts in the spleen whereas (n-3)-rich fed guinea pigs demonstrated an increased number of mycobacteria (p < 0.05). Our results demonstrate that an increased dietary intake of (n-3)-PUFA suppress LTB4 and PGE2 synthesis. The increased number of M. tuberculosis found in the spleens of (n-3)-rich fed animals could represent persistence of the experimental infection. It may be speculated that a functional relationship exists between the two findings.

The fatty acid composition of plasma and erythrocytes in Schistosoma mansoni-infected mice

The fatty acid status of mice six weeks after infection with Schistosoma mansoni was investigated and compared with the status of uninfected mice. Fatty acids of several plasma and erythrocyte lipid fractions were determined by capillary gas-chromatography. Major fatty acids including linoleic acid, arachidonic acid and dihomo-gamma-linolenic acid, were significantly reduced in the plasma phospholipids of infected mice. Arachidonic acid was also reduced in plasma cholesterolesters. The degree of the plasma arachidonic acid reduction in infected animals correlated neither with the worm load nor with the liver weight. The plasma fatty acid changes were not reflected in the lipids of the red blood cells. Since the observed changes in the plasma fatty acid composition occurred early after infection, they are unlikely to be a consequence of portal hypertension. It is speculated that an activation of the eicosanoid metabolism may contribute to these changes.

The diagnosis of pulmonary tuberculosis by gaschromatographic detection of tuberculostearic acid using flame ionisation detectors

It has been shown that the detection of tuberculostearic acid (TBSA) with gas chromatography-mass-spectrometry provides a highly specific, sensitive and rapid method for the diagnosis of various forms of tuberculosis. However, the need for complex and expensive equipment prevented the more widespread use of this method. We report on the application of conventional gas chromatography with flame ionization detectors in the detection of TBSA in sputum samples. TBSA was detected in all patients with proven pulmonary tuberculosis before treatment or under treatment for less than 4 weeks (n = 18). Six of these patients (33%) had a negative microscopy result at the time of the study. Sputum samples from patients under therapy for longer than 4 weeks (n = 20) were TBSA-positive in 15 cases (75%). Only in two cases was the diagnosis by microscopy and/or culture not met by TBSA-detection. All sputa of 20 control patients with lung diseases other than tuberculosis were TBSA negative. Additional analysis of patients' data showed a significant relationship (P < 0.005) between the relative amounts of TBSA detectable in the sputum samples and the duration of therapy. It is concluded that conventional capillary gaschromatography may be sensitive and specific enough to be used for the detection of TBSA in sputum of patients with pulmonary tuberculosis.

Leukotrienes in the pathophysiology of kwashiorkor

The actions of cysteinyl leukotrienes include production of oedema. We investigated whether these mediators might be involved in the oedematous malnutrition syndrome kwashiorkor. The capacity of leukotriene (LT) synthesis by stimulated whole blood and urinary LTE4 excretion was measured in 12 children with kwashiorkor, and compared with that in 24 marasmic and 12 control children. Urinary LTE4 excretion was significantly higher in patients with kwashiorkor than in controls (118.8 [SD 28.5] vs 31.1 [19.3] nmol/mol creatinine; p < 0.01). Whole blood LTE4 synthesis was increased in kwashiorkor patients by a factor of 3.5 (p < 0.01). In marasmic children, LTE4 excretion and synthesis did not differ from those in controls. Although glutathione, known to participate in LTC4 synthesis, was subnormal in erythrocytes of all malnourished patients, whole-blood LTC4 synthesis was higher in kwashiorkor patients than in controls (28.1 [5.0] ng/mL; p < 0.05), and close to control values (9.8 [1.5] ng/mL) in marasmic children. LTB4 synthesis, however, was greatly reduced in kwashiorkor patients (11.5 [2.4] vs 46.5 [6.4] ng/mL; p < 0.01). Inability to synthesise the immunoregulator LTB4 may lead to inefficient chemoattraction of phagocytes and an inadequate inflammatory response in kwashiorkor. The increased endogenous cysteinyl LT generation in kwashiorkor suggests that these lipid mediators are involved in the pathophysiology of the syndrome, particularly in oedema formation.

Scaly skin alterations and plasma fatty acids in Congolese children

Scaly skin alterations on the surface of the legs are frequently found in African children. Because similar signs occur in essential fatty acid deficiency, the fatty acid status of a group of African children with (n = 10) and without (n = 27) such skin alterations was determined. Analysis of the fatty acid composition of the plasma phospholipid and cholesterol ester fractions as well as clinical examinations were performed. Constantly low levels of linoleic acid and arachidonic acid were not associated with the occurrence of scaly skin alterations, which were also found in children with normal values for these polyunsaturated fatty acids. It is suggested that scaly skin alterations in Congolese children are not a sign of essential fatty acid deficiency.

Clinical and biochemical phenotype in 11 patients with mevalonic aciduria

OBJECTIVE

Mevalonic aciduria is a consequence of the deficiency of mevalonate kinase, the first enzyme after 3-hydroxy-3-methylglutaryl-coenzyme A reductase in the biosynthesis of cholesterol and nonsterol isoprenes. To establish the clinical and biochemical phenotype of mevalonic aciduria, the authors assembled their experience with 11 patients including attempts at therapeutic interventions.

METHODS

Mevalonic acid in body fluids was determined by stable isotope dilution gas chromatography/mass spectroscopy with selected ion monitoring, ubiquinone-10 concentrations by reversed-phase high-pressure liquid chromatography.

RESULTS

Varying degrees of severity of clinical illness were observed despite uniform, virtual absence of residual activity of the enzyme. The most severely affected patients have had profound developmental delay, dysmorphic features, cataracts, hepatosplenomegaly, lymphadenopathy, and anemia, as well as diarrhea and malabsorption, and have died in infancy. Less severely affected patients have had psychomotor retardation, hypotonia, myopathy, and ataxia. All patients have had recurrent crises in which there was fever, lymphadenopathy, increase in size of liver and spleen, arthralgia, edema, and a morbilliform rash. Neuroimaging studies revealed selective and progressive atrophy of the cerebellum. Mevalonic acid concentrations were found to be grossly elevated in body fluids of all patients. Concentrations of plasma cholesterol were normal or only slightly reduced. Concentrations of ubiquinone-10 in plasma were found to be decreased in most patients. Abnormalities such as hypoglycemia, metabolic acidosis, or lactic acidemia, the usual concomitants of disorders of organic acid metabolism, were conspicuously absent.

CONCLUSIONS

These observations establish the broad range of clinical symptoms and biochemical findings in mevalonic aciduria. It is concluded that although patients with mevalonic aciduria have a recognizable phenotype of serious clinical manifestations, some patients are likely to remain undiagnosed and may be found in a variety of subspecialty clinics, including neurology, gastroenterology, cardiology, and genetics.

The fatty acid composition of subcutaneous fat in German adults

The fatty acid (FA) composition of subcutaneous fat (SCF) was analyzed in 47 German adults. No influences of sex or age on the FA status of the probands could be detected. SCF consisted mainly of monoenoic fatty acids. Linoleic acid was the major polyunsaturated fatty acid. Linoleic acid metabolites were found in small quantities only. In comparison to the results of studies in the USA and the Netherlands the FA composition of SCF in German probands was characterized by lower levels of linoleic acid and higher contents of palmitic acid. The trans-FA content was similar to that in Dutch women, but lower than in American male probands. However, in evaluating the differences in the FA composition of SCF in different countries, it has to be noted that there are wide ranges in the proportions of the major FA in all populations studied.

Heparin binding lectin of human placenta as a tool for histochemical ligand localization and isolation

Biotinylated heparin has been used to detect the presence of specific binding sites in sections of human placenta, which has prompted demonstration of expression of lectin activity for this proteoglycan. Purification of this lectin from full-term placenta facilitates the synthesis of its biotinylated derivative, using biotin-amidocaproyl hydrazide, without affecting its activity. It also enables immunization to obtain antibodies. The labeled lectin is shown to bind specifically to nuclear and cytoplasmic locations in various cell types of human placenta, nuclear expression of lectin binding sites being more pronounced at the full-term stage than after 8 weeks of development. The structurally related histone H2B exhibits obvious differences in its binding pattern. The presence of ligands accessible to the lectin whose binding activity can be inhibited by addition of an excess of heparin correlates in most instances with the level of lectin expression detected immunohistochemically. Biochemical information on the nature of the glycohistochemically inferred lectin-specific ligand(s) is obtained by affinity chromatography on resin-immobilized lectin. It leads to isolation of a proteoglycan with similar electrophoretic mobility in agarose-polyacrylamide gel electrophoresis relative to the independently purified heparan sulfate-containing fibronectin binding proteoglycan from human placenta. Both fractions inhibit binding of heparin to the lectin and contain immunologically detected co-purified lectin, emphasizing their ligand properties. Application of labeled tissue lectins in conjunction with lectin-specific antibodies is proposed to obtain valuable insights into the expression of the receptor as well as the ligand part of protein-carbohydrate recognition.

Fatty acid analysis of different Candida species by capillary column gas-liquid chromatography

Gas-liquid chromatography was used to analyse the fatty acid composition of whole-cell hydrolysates of 40 yeast strains representing 5 Candida species and Torulopsis glabrata, T. glabrata could be easily distinguished from all other Candida spp. by the absence of C18:3. Candida albicans, C. krusei, C. parapsilosis, C. pseudotropicalis and C. tropicalis showed 10 major peaks in characteristic proportions. C. parapsilosis showed a high C16:0/C16:1 ratio (greater than 4.5), whereas C. pseudotropicalis was characterized by a C18:1/C16:0 ratio of less than 2.0. A high C18:3 concentration (greater than 10%) was typical for C. krusei (C18:2/C18:3 ratio less than or equal to 1.0). Our data reveal characteristic patterns of cellular fatty acid composition of T. glabrata, C. krusei, C. parapsilosis and C. pseudotropicalis which can be used for laboratory identification.

Ultrasonographical investigations of onchocerciasis in Liberia

The efficiency of ultrasonography (US) for the diagnosis and clinical characterization of onchocerciasis was evaluated. US was performed on 120 probands in Liberia. Ninety-two patients had generalized onchocerciasis, 21 patients suffered from the chronic hyperreactive form of onchocerciasis (sowda), and 7 probands served as controls. Patients were examined by US with linear (7.5 MHz and 5 MHz) and sector (3.5 MHz) scanners. US results were evaluated by examination of extirpated nodules. The US structure of nodules revealed a typical pattern consisting of a homogeneous echogenicity with small echodense particles and a lateral acoustic shadow, and differentiation from lymph nodes, lipoma, or fibroma was achieved. Within the onchocercomata, calcifications or fluid were identified. Regarding the estimation of the worm burden, it is important to note that in 24 patients, additional nodules not previously palpated were found by US. Also, the number of worm centers in palpable conglomerate nodules were determined more exactly by US than by palpation. In 4 of 16 sowda patients, impalpable nodules were found by US. In 13 patients with positive microfilaria counts, no nodules could be detected. The highly characteristic ultrasonographical pattern of onchocercomata may serve as a basis for further US investigations in onchocerciasis.

Vitamin E status in Sudanese children with protein-energy malnutrition

Total tocopherols and alpha-tocopherols were estimated in the plasma of children with severe malnutrition (14 marasmus; 11 marasmic kwashiorkor; five kwashiorkor) and related to the total plasma lipids and different plasma lipid classes. If the mere plasma concentrations were taken as an index of the vitamin E status, five children with marasmus, five children with marasmic kwashiorkor, and two children with kwashiorkor would have been regarded as deficient (less than 500 micrograms/dl). However, if total tocopherols and alpha-tocopherols were related to the total plasma lipids, all malnourished children--except one--showed values within the limits found in healthy American children. The study shows that low tocopherol/lipid ratios are not a constant feature in severely malnourished children.

Selenium status in Sudanese children with protein-calorie malnutrition

In 68 Sudanese children with severe protein-energy malnutrition, age 1-4 years, the selenium status was investigated and the results were compared with those of healthy Sudanese and German children. The median selenium content in plasma of healthy Sudanese children (x = 59 micrograms/L) and with those of marasmus (x = 57 micrograms/L) were found to be in the same range. It was lower than in healthy German children (x = 82 micrograms/L). Patients with marasmic kwashiorkor exhibited still lower values (x = 42 micrograms/L. Within each group of malnourished children (marasmus, marasmic kwashiorkor, kwashiorkor) there were patients with low and with "normal" selenium values (taking the values of healthy German children as normal). Hair selenium values were not different between marasmic Sudanese children and healthy German children, probably due to reduced hair growth in malnourished children. Plasma glutathione peroxidase activity was reduced concomitantly with plasma selenium in the patients with protein-calorie malnutrition. There was a good correlation between plasma selenium and plasma glutathione peroxidase activity. A follow-up study showed that plasma selenium decreased during rehabilitation in those patients who had a "normal" value before treatment. This is probably due to the low selenium content of the two dietary formulae used, which contained 18 and 25 micrograms/L Se of formula,. It remains questionable whether the low selenium states and low selenium intake exhibit a healthy risk inhibiting further rehabilitation of the patients with severe protein-calorie malnutrition.

Investigation of the nutritional state of children in a Congolese village. I. Anthropometrical data, plasma prealbumin, albumin, immunoglobulins, ferritin, C-reactive protein, circulating immune complexes

The nutritional status of an unselected group of 111 children from the village of Bouansa, People's Republic of the Congo, was studied. Comprehensive clinical examinations, anthropometrical measurements and analysis of albumin, prealbumin, ferritin, C-reactive protein (CRP), IgA, IgG, IgM, IgE, IgG- and IgM-circulating immune complexes (CIC) were carried out. The results show, by anthropometrical classification, a high prevalence of moderate malnutrition. Low levels of plasma proteins and high levels of immunoglobulins and CIC were found. No correlation between anthropometrical classification and plasma proteins was established. Children with increased levels of CRP showed low prealbumin values and increased levels of ferritin. Patterns of immunoglobulins and CIC were close to those found in other studies in tropical countries. To evaluate the anthropometrical and biochemical findings it is necessary to take into consideration the apparently healthy appearance of the children, which shows the degree of adaptation to the limited availability of food and the high rate of acute and chronic infections.

Investigation of the nutritional state of children in a Congolese village. II. Plasma fatty acid composition

The fatty acid status of an unselected group of 84 Congolese children was determined by estimating the fatty acid composition of the plasma phospholipid (PL) and cholesterolester (CE) fractions using capillary gas chromatography. In comparison with North American and European children a wide range of values and low mean percentages (related to the fatty acids of a chain length of 14-24 carbon atoms) were found for the following fatty acids (mean +/- SD): linoleic acid (LA) (PL: 17.19 +/- 3.85; CE: 40.13 +/- 7.72); arachidonic acid (AA) (PL: 6.60 +/- 2.28; CE 4.32 +/- 1.71); dihomo-gamma-linolenic acid (DHLA) (PL: 1.80 +/- 0.68; CE 0.41 +/- 0.22). On average, omega 3 fatty acids were higher than in reference groups, while similar values were found for the monoenoic and omega 9 fatty acids. No sample contained eicosatrienoic acid, 20:3 omega 9 (ETA) which, dependent on analytical methods, may be difficult to separate from behenic acid (22:0). Changes in the relation between the two lipid fractions occurred when the LA content in CE was less than 35%. Also the correlation between LA and AA in CE, which was significant below 35% LA (r = 0.84), changed with higher values for LA (r = 0.01). These findings may indicate that alterations in fatty acid metabolism occur when LA values in CE--which are supposed to be directly related to the dietary intake of polyunsaturated fatty acids--fall below 35% of all fatty acids in this lipid fraction.

Plasma fatty acid composition of breast-feeding Sudanese women

The status of essential fatty acids has been evaluated in 75 well-nourished Sudanese women of two villages of the irrigated Gezira area. All were consuming local Sudanese food. The fatty acid composition of the plasma cholesterolester and phospholipid fractions was estimated by capillary gas chromatography. Compared to values published from healthy American controls (Holman et al., 1979) their values of linoleic acid, dihomo-gamma-linolenic acid, and arachidonic acid were adequate. Eicosapentaenoic acid and docosahexaenoic acid were found to be lower. Trans fatty acids were very low. With increasing levels of linoleic acid in the phospholipid fraction the arachidonic acid levels decreased, thus showing a regulation of the phospholipid arachidonic acid content. The ratio linoleic acid/dihomo-gamma-linolenic acid, reflecting the delta 6-desaturation and the following elongation step, increased with rising linoleic acid values.