[Current evidences in shockwave treatment. SETOC (Spanish Society of Shockwave Treatment) recommendations]

This SETOC consensus document shows the scientific evidence of the technology in shockwaves (SW) and radial pressure waves (RPW) in a variety of spasticity disorders, musculoskeletal, skin, urological diseases, etc. SW and RPW, without anesthesia, are an effective, safe, non-invasive, cost-effective treatment, which reduces the need for surgery, lower risk of complications, faster recovery and greater acceptability to patients than surgery. Consequently, SW and RPW should be the first therapeutic option in the aforementioned chronic pathologies, when conservative alternatives have failed. SETOC advises to follow the recommendations given in this article, including the ones given by SW scientific societies and best evidence for each technology as well.

A new strategy of delayed long-term prophylaxis could prevent cytomegalovirus disease in (D+/R-) solid organ transplant recipients

Long-term prophylaxis against cytomegalovirus (CMV) started immediately after transplantation in (D+/R-) poses a higher risk of late-onset CMV disease. Delayed CMV prophylaxis could allow a transitory exposure of the immune system to CMV, which would let the immune system mount an adequate CMV-specific cytotoxic response in (D+/R-) patients and confer protection against CMV disease. We included all (D+/R-) solid organ transplant recipients (SOT) performed at our institution (January 3/October 6) who received CMV prophylaxis (mainly with oral valganciclovir) during 100 d. In the first period (until December 4), prophylaxis was initiated immediately after transplantation (conventional prophylaxis: CP). Since January 5, it was initiated after 14 d (delayed prophylaxis: DP). Incidence and severity of CMV disease was compared between both groups. A total of 44 SOT recipients were included (CP: 26 and DP: 18). CMV disease was diagnosed in eight patients (18%), seven of 26 (27%) in the CP group, and one of 18 (5.5%) in the DP group (p = 0.07). CMV colitis was reported in five of 26 patients in the CP group (19%), whereas there were no cases of visceral CMV disease in the DP group (p = 0.048). A 14-d delay in the beginning of long-term prophylaxis against CMV in (D+/R-) is safe and could prevent the onset of late-CMV disease.

Analysis of competing risks of causes of death and their variation over different time periods in Hodgkin disease

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Background: Hodgkin’s disease is put forward as a model of curable illness. However, long-term studies show an excessive mortality in relation to the general population. The only way for detecting these causes are the long-term follow-up clinical studies, even these long-term follow-ups may not be fully representative of current causes of death. Methods: All patients diagnosed with HD at the University Hospital “Clínica Puerta de Hierro” between 1967 and 2003 were included. The competing risks of causes of death and the vital situation were examined in three time periods. Three cohorts were compared: cohort A with patients treated before 1980, B with those treated 1981–1986 and C from 1986 on. Results: We studied 534 patients, with a median follow-up time of 9.1 years for the whole cohort. The 5, 15 and 20-year Kaplan-Meier survival estimates for all patients were 81%, 72% and 65%, respectively. At the close of the study, 337 (63.1%) were alive and 170 (31.8%) had died. In general, the most common cause was the progress of Hodgkin’s disease, followed by deaths due to a second tumor. By time periods, we found statistically significant differences between cohort A and the other two cohorts, with less LD and MC histology, fewer advanced stages and fewer combined treatments in the latter. Between cohorts B and C there were only differences in the histological results, with less LD and MC and increased NS in the latter. Survival was significantly worse in the first period than in the other two (p<0.001) and in the three periods the main cause of death was tumor progression. Conclusions: The progression of Hodgkin’s disease is the main cause of death in all the periods studied. Over time a clear reduction in death related to the toxicity of treatments was seen. In the light of our results, the question is posed as to whether the survival and causes of death series for those patients treated since the 1970s are telling us about a real situation. Patients die now for reasons that are different from in the 1970s and this is important when planning preventive and clinical research activity.

No significant financial relationships to disclose.

Irreversible coma, ergotamine, and ritonavir

We report the first case in the medical literature (to our knowledge) of a patient with human immunodeficiency virus infection who was being treated with ritonavir and developed signs of severe vascular involvement and irreversible coma after the administration of 3 mg of ergotamine tartrate.

Severe cutaneous vasculitis following intravenous infusion of gammaglobulin in a patient with type II mixed cryoglobulinemia

Intravenous infusion of gammaglobulins (IVIG) is one of the treatments of choice in patients with type II mixed cryoglobulinemia (MC). We describe the case of a patient with MC who suffered an adverse generalised reaction with severe cutaneous vasculitis accompanied by a sudden increase in cryocrit levels shortly after being treated with IVIG. When the same gammaglobulin preparation was added in vitro to a sample of the patient's serum, a strong increment in cryoglobulin precipitation and depletion of the monoclonal IgM peak resulted. We suggest that this simple method of studying the displacement of the precipitation reaction could help to predict the outcome of treatment and must be performed before starting IVIG in patients with MC.

[Coxiella burnetii endocarditis: long-term clinical course in 20 patients]

INTRODUCTION AND OBJECTIVES

Coxiella burnetii is a causative agent of increasingly frequent subacute infective endocarditis, and is associated with elevated morbimortality. Our aim in the present study was to assess the clinical, serological and therapeutic long-term evolution of 20 patients with Coxiella burnetii endocarditis.

METHODS

Twenty patients (13 male and 7 female, age 42 +/- 10 years) admitted between 1982 and 1996 were retrospectively studied. All of them fulfilled the Duke criteria modified by Raoult for Q fever endocarditis.

RESULTS

Endocarditis involved prosthetic and native valves in 14 and 6 patients, respectively. All patients except one received antibiotic treatment. Patients treated with doxycycline in monotherapy showed worse evolution than those treated with doxycycline in combination with other antibiotics. Valve replacement was performed in 15 patients, due to prosthetic dysfunction in most of them. The overall mortality was 40% (8 patients). At follow-up of 74 months (range 19-156) (mean 74 +/- 47) all patients showed persistent high levels of phase I antibodies. At follow-up of 15 to 65 months (32 +/- 30) antibiotic treatment was suspended in five patients because they were asymptomatic and without microbiologic findings of valvular endocarditis.

CONCLUSIONS

Q fever endocarditis was associated with severe complications, which often required valve replacement. All patients showed persistent high serological titers of Coxiella burnetii endocarditis without other signs of active infection. This finding raises the issue of suspending antibiotic treatment in patients with negative microbiologic findings and questions the persistence of abnormal serology as a monitor of treatment efficacy.

Sustained response to interferon-alpha or to interferon-alpha plus ribavirin in hepatitis C virus-associated symptomatic mixed cryoglobulinaemia

BACKGROUND

Hepatitis C virus (HCV) infection has been associated with mixed cryoglobulinaemia.

AIM

To investigate the efficacy of anti-viral therapy on the eradication of HCV and its clinical manifestations in patients with HCV-associated symptomatic mixed cryoglobulinaemia.

PATIENTS AND METHODS

18 out of 32 patients with symptomatic mixed cryoglobulinaemia (MC group) received a 12-month course of interferon (3 MU three times a week, subcutaneously). Nonresponders or relapsers to this therapy were treated with interferon plus ribavirin (1200 mg/day, orally) for 12-months. 226 patients with HCV infection and without cryoglobulins were studied in comparison (Hepatitis C group). Serial quantification of serum HCV-RNA and cryoglobulins were performed.

RESULTS

In the MC group, 10 out of 18 patients (55%) receiving interferon showed an end of treatment response, but at the end of follow-up, only five (28%) patients had a sustained response. In the hepatitis C group, 91 patients (47%) showed an end of treatment response but only 42 (20%) a sustained response. In the MC group alanine transaminase, cryocrit and rheumatoid factor decreased significantly in responders, with an improvement or disappearance of the MC-associated clinical manifestations. Alanine transaminase, cryocrit and rheumatoid factor increased in the relapsers and the clinical manifestations reappeared. Nonresponders and relapsers to interferon in the MC group were retreated with interferon plus ribavirin. Five out of eight nonresponders showed a end of treatment response but it was sustained in three of them. In the relapsers, treatment with combined therapy achieved a sustained response in four out of the five patients (80%).

CONCLUSIONS

Interferon as monotherapy or combined with ribavirin is a safe and effective treatment in patients with HCV-associated MC. The presence of cryoglobulins does not affect the response to anti-viral treatment in patients with HCV infection. The eradication of HCV is associated with an improvement or disappearance of MC-associated clinical manifestations.

Urokinase-type plasminogen activator binding to its receptor stimulates tumor cell migration by enhancing integrin-mediated signal transduction

Urokinase-type plasminogen activator (uPA) and its receptor (uPAR) participate in matrix degradation and cell migration by focusing proteolysis and functioning as a signaling ligand/receptor complex. uPAR, anchored by a lipid moiety in the membrane, is thought to require a transmembrane adapter to transduce signals into the cytoplasm. To study uPAR signaling, we transfected the prostate carcinoma cell line LNCaP, which does not express endogenous uPA or uPAR, with a uPAR encoding cDNA, resulting in high-level surface expression. We studied migration of these cells on fibronectin, which is mediated by the integrin alpha5beta1. Ligation of uPAR with uPA or its amino-terminal fragment enhanced haptotactic migration to fibronectin. In cells on fibronectin, but not on poly-l-lysine, ligation of uPAR also resulted in tyrosine phosphorylation of several proteins, including two proteins involved in integrin signaling, focal adhesion kinase and the crk-associated substrate p130(Cas). Furthermore, after uPAR ligation, uPAR was co-immunoprecipitated with beta1 integrins from the detergent-insoluble fraction of cell lysates. Thus, our data suggest that uPAR occupancy results in an interaction between uPAR and integrins and a potentiation of integrin-mediated signaling, which leads to enhanced cell migration.

Three cases of tuberculosis after heart transplantation in Spain

Three cases are presented of tuberculosis occurring in a series of 410 heart transplant recipients in a Spanish hospital, representing a rate of 0.73%. Twenty-eight cases reported in the literature are also reviewed. In most series reported, tuberculosis occurred in a small percentage of heart transplant recipients, the average rate being 1.25%. Compared to the general population, a higher percentage (28%) of extrapulmonary and disseminated forms of the disease is seen in these patients. Although a cure without recurrence can usually be achieved with a conventional anti-tuberculous antibiotic regimen, the disease is still associated with a significant mortality rate of 11%. Guidelines for the early diagnosis and treatment of these patients are discussed.

Distribution of IgA subclass response to Coxiella burnetii in patients with acute and chronic Q fever

The progression of Coxiella burnetii infection to acute or chronic Q fever has been attributed to biological characteristics of the bacterium and to the host immune response. We measured whether serum levels of total and specific subclasses IgA1 and IgA2 could be correlated with the course of disease in acute and chronic Q fever infections, and with the occurrence of endocarditis. In patients with chronic infection, total IgA2 levels were significantly increased. Q-fever-specific IgA1 antibodies were detectable in both acute and chronic infections, but only patients with endocarditis had IgA2 antibodies to C. burnetii phase II antigens. These findings indicate that the measurement of IgA subclasses may be a useful aid in the serological diagnosis of Q fever. Our results reinforce the idea that immunologically mediated host factors are important in the pathogenesis of Q fever and in the disease outcome of this infection.

[Visceral leishmaniasis in immunocompromised patients]

OBJECTIVE

Most patients who developed visceral leishmaniasis (VL) in our country are ímmunocompromised (IC) host, frequently HIV-infected patients. One objective was to know if there were differences about the clinical manifestations, diagnostic tests or prognosis in IC patients who were infected or not with HIV (HIV+ and HIV-, respectively). Also we wonder if some features were associated with death during the initial episodes of VL.

METHOD

We studied 16 IC patients with VL, 9 were VIH+ and 7 were VIH-. Most frequently observed findings were fever (94%), splenomegaly (81%), hepatomegaly (69%), and constitutional syndrome (50%). HIV+ patients had symptoms during a lapse of time (70 +/- 78 days) larger than the VIH- cases had (17 +/- 12 days, p < 0.05).

RESULTS

We performed a serology to Leishmania sp in 15 cases (94%) and were positive in 13 patients (77% in HIV+ and 100% in VIH patients). Seven patients (44%, 4 VIH- and 3 VIH+) died during the initial episode of VL. Nine patients (66%) who survived to it were followed-up during 68 +/- 49 months. Seven patients (4 VIH+ and 3 VIH-) showed several relapses (2.5 +/- 1.6 relapses/patient) through the follow-up. The patients who died during the initial episode had more frequently (p < 0.05) concentrations of albumin below 3 g/dl or of globulins below 4 g/dl, than the survivors had. The CD4+ lymphocyte counts in HIV+ patients were lower in patients who died during the initial episode of VL (19 +/- 15/mm) than in survivors (108 +/- 67/mm3, p = 0.07).

[Detection of human herpesvirus 8 in patients with Kaposi's sarcoma or Castleman's disease associated with AIDS]

A new herpesvirus provisionally termed as KSHV or HHV-8 has been detected in lesions from AIDS-based Kaposi's sarcoma (KS) and from other KS clinical forms, and also in other tumors such as body cavity-based lymphomas or Castleman's disease (CD). We have assessed the presence of this novel herpesvirus in specimens from patients diagnosed with either AIDS and KS or AIDS and CD. DNA samples from skin lesions and peripheral blood obtained from 8 patients diagnosed with AIDS, seven with KS and one with multicentric CD were analyzed; skin specimens and peripheral blood samples from volunteer blood donors or from KS and CD free HIV seronegative patients were used as controls. Detection of the virus was done by PCR amplification of KS330 region, one of the HHV-8 sequences first reported. All skin lesions analysed tested positive for KS330; peripheral blood samples from 5 of the patients, including the one diagnosed with CD, showed also the virus sequence. All skin specimens and peripheral blood samples from controls were negative. From our results it can be concluded that the novel herpesvirus HHV-8 can also be detected in patients with AIDS-associated KS and AIDS-associated CD in Spain.

Requirement of receptor-bound urokinase-type plasminogen activator for integrin alphavbeta5-directed cell migration

The urokinase plasminogen activator (uPA) interacts with its cell surface receptor (uPAR), providing an inducible, localized cell surface proteolytic activity, thereby promoting cellular invasion. Evidence is provided for a novel function of cell surface-associated uPA.uPAR. Specifically, induction of cell surface expression of uPA. uPAR by growth factors or phorbol ester was necessary for vitronectin-dependent carcinoma cell migration, an event mediated by integrin alphavbeta5. Cell migration on vitronectin was blocked with either a soluble form of uPAR, an antibody that disrupts uPA binding to uPAR, or a monoclonal antibody to alphavbeta5. Moreover, plasminogen activator inhibitor type 2 blocked this migration event but did not affect adhesion, suggesting a direct role for uPA enzyme activity in this process and that migration but not adhesion of these cells is regulated by uPA.uPAR. Growth factor-mediated induction of uPA.uPAR on the carcinoma cell surface promotes a specific motility event mediated by integrin alphavbeta5, since cells transfected with the beta3 integrin subunit expressed alphavbeta3 and migrated on vitronectin independently of growth factors or uPA.uPAR expression. This relationship between alphavbeta5 and the uPA.uPAR system has significant implications for regulation of motility events associated with development, angiogenesis, and tumor metastasis.

Suppression of p53 activity and p21WAF1/CIP1 expression by vascular cell integrin alphaVbeta3 during angiogenesis

Induction of p53 activity in cells undergoing DNA synthesis represents a molecular conflict that can lead to apoptosis. During angiogenesis, proliferative endothelial cells become apoptotic in response to antagonists of integrin alphavbeta3 and this leads to the regression of angiogenic blood vessels, thereby blocking the growth of various human tumors. Evidence is presented that administration of alphavbeta3 antagonists during angiogenesis in vivo selectively caused activation of endothelial cell p53 and increased expression of the p53-inducible cell cycle inhibitor p21WAF1/CIP1. In vitro studies revealed that the ligation state of human endothelial cell alphavbeta3 directly influenced p53 activity and the bax cell death pathway. Specifically, agonists of endothelial cell alphavbeta3, but not other integrins, suppressed p53 activity, blocked p21WAF1/CIP1 expression, and increased the bcl-2/bax ratio, thereby promoting cell survival. Thus, ligation of vascular cell integrin alphavbeta3 promotes a critical and specific adhesion-dependent cell survival signal during angiogenesis leading to inhibition of p53 activity, decreased expression of p21WAF1/CIP1, and suppression of the bax cell death pathway.

Induction of carcinoma cell migration on vitronectin by NF-kappa B-dependent gene expression

Integrin alpha v beta 5 promotes FG carcinoma cell adhesion to vitronectin yet requires protein kinase C (PKC) activation for migration on this ligand. Here we report that this PKC-dependent cell motility event requires NF-kappaB-dependent transcription. Specifically, a component within nuclear extracts prepared from PKC-stimulated FG cells exhibited a significant increase in binding activity to a synthetic oligonucleotide containing a consensus kappa B sequence. These nuclear DNA-binding complexes were shown to be comprised of p65 and p50 NF-kappaB/rel family members and appeared functionally active because they promoted transcription of a reporter construct containing a kappa B site. The NF-kappa B activation event was directly linked to the alpha v beta 5 motility response because the NF-kappa B-binding oligonucleotide, when introduced into FG cells, inhibited cell migration on vitronectin but not on collagen and had no effect on cell adhesion to either ligand. These results suggest that the detected DNA-binding complexes interact with kappa B transcriptional elements to regulate gene expression required for alpha v beta 5-dependent cell motility on vitronectin.

Receptor tyrosine kinase signaling required for integrin alpha v beta 5-directed cell motility but not adhesion on vitronectin

FG human pancreatic carcinoma cells adhere to vitronectin using integrin alpha v beta 5 yet are unable to migrate on this ligand whereas they readily migrate on collagen in an alpha 2 beta 1-dependent manner. We report here that epidermal growth factor receptor (EGFR) activation leads to de novo alpha v beta 5-dependent FG cell migration on vitronectin. The EGFR specific tyrosine kinase inhibitor tyrphostin 25 selectively prevents EGFR autophosphorylation thereby preventing the EGF-induced FG cell migration response on vitronectin without affecting constitutive migration on collagen. Protein kinase C (PKC) activation also leads to alpha v beta 5-directed motility on vitronectin; however, this is not blocked by tyrosine kinase inhibitors. In this case, PKC activation appears to be associated with and downstream of EGFR signaling since calphostin C, an inhibitor of PKC, blocks FG cell migration on vitronectin induced by either PKC or EGF. These findings represent the first report implicating a receptor tyrosine kinase in a specific integrin mediated cell motility event independent of adhesion.

T lymphocytes from alcoholic cirrhotic patients show normal interleukin-2 production but a defective proliferative response to polyclonal mitogens

T lymphocyte proliferation is a complex process involving intra- and extracellular molecules. T cell activation was studied in T lymphocytes from patients with alcoholic cirrhosis. A defective phytohemagglutinin (PHA)-induced T cell mitogenesis was observed in 60% of these patients. Likewise, their blastogenic response to anti-CD3 was also depressed (p < 0.05). However, the DNA synthesis induced by stimulation with phorbol esters (12-O-tetradecanoil-phorbol-13-acetate) + ionomycin was normal (p > 0.05). These alterations cannot be ascribed either to decreased interleukin-2 synthesis or to a defective interleukin-2 receptor expression after cellular activation. Moreover, supplementation of the PHA-stimulated T cell cultures with saturant concentrations of recombinant interleukin-2 did not normalize the hypoproliferative response of T cells from alcoholic++ cirrhotic patients. These results provide evidence that a generalized alteration in the interactions between either mitogens or interleukin-2 and their receptors can explain the T lymphocyte-defective blastogenesis found in patients with alcoholic cirrhosis.

[Autoimmune hemolytic anemia associated with ulcerative colitis arising after colectomy]

Autoimmune hemolytic anemia is a rare, although not exceptional, complication of ulcerative colitis. This report presents a case of this association, which is noteworthy in that the hematologic picture appeared immediately after colectomy was performed due to colonic perforation. The features of the only three reported cases in which anemia developed after colectomy are reviewed, and the role of this surgical technique in the treatment of hemolytic anemia associated with ulcerative colitis is discussed. Although colectomy does not protect patients with ulcerative colitis from the onset of hemolytic anemia, we consider that proctocolectomy should be included among the therapeutic alternatives when this association is present, especially in the case of refractory colitis.

[Amyloidosis and sleep-inhibiting apnea. A case improved by continuous positive pressure applied via the nose]

We present a patient with primary amyloidosis and sleep-inhibiting apnea and review the only two cases for which adequate references have been made in the medical literature. The importance of a complete anamnesis on the characteristics of sleep are stressed, and it is suggests that treatment with positive pressure applied via the nose (cPAP), as in the case presented here, can mean an important symptomatic improvement in a disease with an unfortunate prognosis.

[Giant-cell myocarditis: a systemic disease? Apropos a case]

Giant cell myocarditis is a rare disease of unknown etiology, which develops as a myocardial isolated affection or associated to different diseases. Its characteristics are such as necrosis, inflammation and giant cell presence in the myocardium. We present the case of a woman who suffered of giant cell myocarditis, thymoma, myasthenia gravis, chronic lymphocytic thyroiditis, giant cell myositis, granulomatous infiltration in the lymph nodes of the hilus of the lung and hypogammaglobulinemia; multiple association that we have not found in any published medical paper and that suggest the autoimmune origin of this illness. The cardiovascular symptoms and the associated diseases are revised, and we discussed the diagnostic and therapeutic topics, pointing out the necessity to take it into account for any patient with thymoma or myasthenia gravis developing to heart failure or arrhythmias.

Double disease in rheumatology: coexistence of rheumatoid arthritis and psoriatic arthritis

Since rheumatoid arthritis (RA) and psoriatic arthritis (PA) are common diseases, there should be a group of patients in which the two entities coexist, with an estimated prevalence ranging from 0.03/10,000 to 0.15/10,000. The two entities may share clinical, analytic and radiologic features that further complicate the diagnosis. We report here a patient in whom RA and PA coexisted. The features that differentiate peripheral arthritis in RA and PA are discussed.

Delta 9-tetrahydrocannabinol suppresses concanavalin A induced increase in cytoplasmic free calcium in mouse thymocytes

It has been shown that delta-9-tetrahydrocannabinol (THC) suppresses thymocyte, lymph node, and splenic lymphocyte proliferation in response to a mitogenic stimulus. It has also been reported that increases occur in the cytosolic free calcium concentration (Ca2+) in mitogen treated lymphocytes. In an attempt to understand a portion of the molecular basis of the THC induced suppression of lymphocyte proliferation, we have examined the effects of THC on the Concanavalin A (Con A) induced cytosolic free Ca2+ mobilization in mouse thymocytes measured by fluorescent Ca2+ probes and spectrofluorometry. The results show that a 10 minute pretreatment with THC suppresses the normal rise in intracellular free Ca2+ in response to Con A. A THC concentration of 4 micrograms/ml (13 microM) was suppressive and the drug vehicle, DMSO, had no effect. In addition, we found that THC pretreatment did not inhibit the binding of FITC labeled Con A to the thymocytes suggesting that the drug did not interfere with lectin binding to the cell surface. To further define the nature of the Ca2+ response affected by THC, mouse thymocytes containing fura-2 were exposed to Con A either in the presence or absence of Ca(2+)-containing medium. It was observed that THC abrogated both intracellular release (measured in Ca(2+)-free medium) as well as extracellular Ca2+ influx. These results suggest that a portion of the proliferation defect in THC treated lymphocytes may be related to a drug induced inhibition of Ca2+ mobilization that normally occurs following mitogen treatment.

[Thalassemia minor with iron overload: genetic and clinical study of a family]

A patient with thalassemia minor (TM) is reported who ingested 80 g of alcohol/day and presented an important overload of iron with deposits and a hepatic iron ratio compatible with primary hemochromatosis. The results obtained from the study of histocompatibility antigens, clinical manifestations and family analysis discarded the possibility of two genetic diseases, beta-thalassemia and primary hemochromatosis, being concomitantly present in the same progeny. Thalassemia minor and alcoholic hepatopathy are considered as having acted together and being responsible for the iron overload. The relation between alcohol ingested, TM and iron deposits is discussed.

Interleukin 2 production in a family with systemic lupus erythematosus and a C4Q0 heterozygous inheritance

Interleukin 2 production was studied in a family with systemic lupus erythematosus (SLE) and a C4Q0 heterozygous inheritance. Autoimmune manifestations seemed to be associated with the HLA haplotype containing the C4Q0 allele, which was shared by all four ill family members. Concentrations of interleukin 2, however, did not associate either with the haplotype or with the clinical or serological manifestations, as diminished concentrations of interleukin 2 were found in only two subjects with SLE. Thus the defect in this family seemed to be acquired rather than genetically conditioned.

Hepatic fibrin-ring granulomas: a clinicopathologic study of 23 patients

Twenty-three patients with characteristic hepatic fibrin-ring granulomas were studied. Q fever accounted for 10 cases (43%), visceral leishmaniasis for five cases (22%), boutonneuse fever for two cases (9%), and toxoplasmosis, Hodgkin's disease, and allopurinol hypersensitivity for one case each (4%). The etiology remained undetermined in three cases (13%). This report broadens the range of etiologies of hepatic fibrin-ring granulomas to include boutonneuse fever and toxoplasmosis in the differential diagnosis of ring granulomas, and it could serve as a guideline to the clinician and pathologist for the most frequent categories of disease associated with this morphologic pattern.

Late relapse with nodular lymphoma after treatment for diffuse non-Hodgkin's lymphoma

Histologic conversion from a low-grade non-Hodgkin's lymphoma (NHL) into a more aggressive histologic pattern is a common, well-documented event in NHL. The converse phenomenon, appearance of a low-grade, follicular NHL after treatment for diffuse, intermediate, or high-grade NHL, has only recently been recognized. The clinical, morphologic, and immunologic features of a patient in whom relapse with an indolent nodular lymphoma was noticed after combination chemotherapy for diffuse lymphoma are presented. Immunologic markers at presentation and relapse were similar. Other previously reported cases are reviewed. Implications for diagnosis and therapy as well as the pathogenesis of this unique form of conversion are discussed.