A case of microscopic polyarteritis nodosa with interstitial pneumonia successfully treated with steroid pulse therapy and immunosuppressive agents

We report a patient with microscopic polyarteritis nodosa (mPN) and interstitial pneumonia, who was subjected to investigation by bronchoalveolar lavage (BAL), thoracic computerized tomography (CT) and gallium-67 citrate (67Ga) scintigraphy before and after administration of glucocorticoid and immunosuppressive agents. Renal function, renal histology, interstitial inflammation of the lung, and pulmonary function and histology improved cytoplasmic autoantibody (MPO-ANCA), which decreased with decreasing disease activity after starting treatment. Interstitial pneumonia may be associated with pulmonary capillaritis due to mPN. Methylprednisolone pulse therapy followed by oral prednisolone and immunosuppressive agents is considered to be an effective therapeutic strategy for combined mPN and interstitial pneumonia.     

Severe Legionella micdadei pneumonia effectively treated with hemofiltration therapy

A 42-year-old man was admitted because of fever, productive cough, and progressive dyspnea. Chest x-ray films and computed tomographic scans disclosed dense consolidation in the left and right lung fields. No pathogenic agent was found despite extensive bacteriological examinations. Based on serological findings, the patient was given a diagnosis of acute pneumonia caused by Legionella micdadei. It has been reported that Legionnaire's disease is easily complicated by fatal systemic illnesses such as disseminated intravascular coagulation (DIC) and multiple organ failure. In fact, the patient suffered from severe hypotension and DIC on admission. Treatments against systemic complications were started together with intravenous administration of antibiotics including erythromycin. Continuous intravenous cathecolamin, however, failed to alleviate the patient's shock. We therefore applied endotoxin eliminating therapy using a polymyxin-B-column (PMX) and continuous hemofiltration (CHF). The patient recovered from critical shock immediately after the start of PMX, which together with CHF, alleviated his systemic complications. Although the factors responsible for fatal systemic complications in Legionnare's disease are not well-documented, our findings suggested that some substances removable by PMX and CHF play an important role in pathogenesis.     

Interstitial pneumonia preceding systemic sclerosis

Spontaneous intramural dissection of the oesophagus has been recognized as a separate clinical entity between a transmural oesophageal rupture (Boerhaave syndrome) and an oesophageal mucosal tear (Mallory-Weiss syndrome). It is important to differentiate this condition from myocardiac infarction, dissecting aneurysm and other acute surgical conditions. Conservative management is usually thought to be adequate. We report a case of spontaneous intramural oesophageal dissection, in which the symptom of dysphagia did not improve with the conservative management and an endoscopic incision of the septum between true and false lumens using a needle-type diathermy knife was done safely and effectively.     

Interstitial pneumonia associated with mixed connective tissue disease--marked improvement with azathioprine

Polyarteritis Nodosa (PAN) is a rare disease in childhood. No single pattern of clinical presentation characterizes this disease, but abdominal pain, central or peripheral nervous system disease, arthritis, myalgia and skin lesions occur at some time during the course of the illness. In this case a 16-year-old boy who presented with abdominal pain, elevated sedimentation rate associated with hypertension, and a high level of renin, all of which were detected during his hospitalization, suggested the diagnosis of PAN, and renal angiography was performed. Characteristic renal aneurysms were visualized and the diagnosis was confirmed.     

Elevated interleukin-12 in progressive multiple sclerosis correlates with disease activity and is normalized by pulse cyclophosphamide therapy

The technique of pulse radiolysis has been used to investigate the possibility of intramolecular charge transfer in the dipeptide histidyltyrosine, following one-electron oxidation of one of its amino acid residues. The radical anion, Br2.- was found to react with the dipeptide at pH 6.0 with a bimolecular rate constant of 2.3+/-0.2 x 10(7) dm3 mol(-1)s(-1) suggesting that it reacts very selectively with the histidine moiety. Spectral observations at, or close to the end of this reaction show only the presence of a tyrosinyl free radical (TyrO.), however, indicating that fast (>10(6) s(-1) intramolecular charge transfer has taken place between histidine radicals (His+.) and tyrosine (TyrOH). This finding was supported by the direct observation of the rate of formation of TyrO. in experiments with the free amino acids, histidine and tyrosine, under conditions where Br2.- reacted selectively with histidine. The bimolecular rate constant for the reaction between His+. and TyrOH was found to be 2.4+/-0.5 x 10(6) dm3 mol(-1)s(-1). Taken together, the results of the study indicate that His+. is a relatively strong oxidising agent where (E (His+./His) > 770 mV at pH 6.0.     

Myeloma ascites--a favorable outcome with cyclophosphamide therapy

PURPOSE: To find out the role of Catalin in the prevention of posterior capsular opacification (PCO), we undertook this experimental study in rabbits. METHODS: Twenty rabbits (10 for the Catalin group and 10 for the placebo group) were operated on for extracapsular clear lens extraction in an aseptic environment. In all cases, capsulorrhexis of 8 mm diameter was carried out. Both the test drug and placebo were given at a dose of 4 times/day from the first postoperative day for 8 weeks. Common drugs in both groups were topical corticosteroid, antibiotic and cycloplegic drops. Periodic slitlamp examinations and photographic documentations were carried out to find any evidence of aftercataract. At the end ot 8 weeks, histopathological examination was carried out to document any evidence of aftercataract. RESULT: Overall, evidence of aftercataract was seen in 6 rabbits in the control group and 3 in the Catalin group; the degree of PCO was higher in the placebo group. CONCLUSION: We found that Catalin played some role in preventing PCO.     

Bladder cancer in patients with multiple sclerosis treated with cyclophosphamide

PURPOSE: We define the risk of bladder cancer in multiple sclerosis related to the use of indwelling catheters and cyclophosphamide administered as an immunomodulating agent. MATERIALS AND METHODS: We retrospectively reviewed the records of 2,351 patients with multiple sclerosis referred to the National Center for Multiple Sclerosis. RESULTS: Of the 2,351 patients 2 women and 5 men (0.29%) had bladder cancer. Of the 850 chronically catheterized patients the incidence was 0.7%. One patient with cancer performed intermittent catheterization for a rate of 0.23% in this group. In a subgroup of 70 patients treated with cyclophosphamide 5 chronically catheterized patients (5.7%) had bladder cancer. Hematuria was the most common presenting symptom. These data were compared with those in the literature on bladder cancer in spinal cord injury. CONCLUSIONS: These data suggest a possible synergistic role of cyclophosphamide and chronic catheterization in the induction of secondary bladder cancer. Regular cystoscopy is warranted in these patients to allow early detection of bladder tumors. Nitric oxide metabolism may be an important factor in the carcinogenesis of this type of bladder cancer.     

Severe measles-associated pneumonia treated with assisted ventilation

Measles-associated pneumonia, which was severe enough to require mechanical ventilation, caused a mortality of 64%. The main indications for special respiratory care were severe infection and hypoxaemia. Complications of the disease occurred in 78% of the patients. The commonest were anaemia, enteritis and cardiac failure, and they contributed to the grave prognosis. Viral pneumonia was present in most of the patients who died; superinfection was rare. The characteristics of measles virus was present in 30% and of adenovirus in no less that 40%.     

Chronic eosinophilic pneumonia successfully treated with suplatast tosilate

STUDY OBJECTIVE: To review the epidemiology of hepatitis C virus (HCV) infection among injecting drug users (IDUs) in Australia, and consider needs for further research and prevention policies and programmes. DESIGN: (1) Review of the results of surveillance for HCV; (2) review of published literature on prevalence, incidence, and risk factors for HCV among IDUs; and (3) reconstruction of incidence rates from prevalence studies of HCV in IDUs. SETTING AND PARTICIPANTS: Field and clinic based studies of IDUs in Australia. MAIN RESULTS: HCV has been present at high prevalences (of the order of 60-70%) in populations of Australian IDUs since at least 1971. Duration of injecting and main drug injected were the main predictors of seropositivity, the latter possibly a surrogate for frequency of injecting and both together as surrogate for cumulative numbers of times injected. Risk of infection begins with first injection and continues as long as injecting does. Current incidence is approximately 15 per 100 person years, and up to 40 per 100 person years in some subpopulations. Incidence may have decreased through the 1980s as a result of behaviour change in relation to HIV, as it has for hepatitis B, but not significantly so. CONCLUSIONS: Control of HCV infection in Australia will depend on effectiveness of measures to control HCV spread among IDUs. This will be a greater challenge than the control of HIV in this population has been. Needs identified include improved surveillance, especially for recently acquired infection, better understanding of exact transmission modes, and urgent improvement in prevention strategies.     

Discontinuation of prophylaxis for Pneumocystis carinii pneumonia in HIV-1-infected patients treated with highly active antiretroviral therapy

BACKGROUND: Prophylactic drugs for Pneumocystis carinii pneumonia (PCP) are strongly recommended for HIV-1-infected patients with CD4 cell counts of less than 200 cells/microL. Because of the highly active antiretroviral therapy (HAART) currently available, we speculated that prophylaxis can be discontinued in patients with CD4 cell counts of more than 200 cells/microL. METHODS: In this prospective observational study, PCP prophylaxis (primary or secondary) was discontinued in HIV-1-infected patients whose CD4 cell count had increased above 200 cells/microL (documented twice with an interval of at least 1 month) as a result of HAART. Patients and their CD4 cell counts were monitored every 3 months. The primary endpoint of the study was the occurrence or reoccurrence of PCP. FINDINGS: 78 patients were enrolled: 62 patients were receiving prophylaxis for primary prevention of PCP and 16 patients for secondary prevention of PCP. At the time of discontinuation of prophylaxis, the mean CD4 cell count was 347 cells/microL, and HIV-1-RNA was not detectable in 61 patients. The lowest mean CD4 cell count during prophylaxis was 79 cells/microL. Patients stopped prophylaxis 9.8 (SD 6.4) months after they started HAART. The mean follow-up after discontinuation of prophylaxis was 12.7 (SD 7.6) months, and none of the patients developed PCP (97.5% one-sided CI 0-4.4%). INTERPRETATION: The preliminary results of this study indicate that PCP prophylaxis can be stopped safely in HIV-1-infected patients whose CD4 cell counts have increased above 200 cells/microL after treatment with HAART.     

Potentiation of the 5-aminolevulinic acid-based photodynamic therapy with cyclophosphamide

We have investigated the efficacy of the Photodynamic Therapy (PDT) from 5-aminolevulinic acid (ALA) in combination with an antineoplastic agent using an in vitro-in vivo model developed in our laboratory. The alkylant cyclophosphamide (CY) was chosen because there is evidence of the porphyrinogenic properties of this drug. Male BALB/c mice bearing a transplantable mammary adenoarcinoma were given two doses of 35 mg de CY/kg wt. i.p. and 9 mg/kg wt intratumorally. At 16, 22 and 40 hrs after the last injection of CY the animals were sacrificed and explants of 2 mg of tumor were incubated 2 hrs in a medium containing 0.6 mM ALA; and then irradiated with a He-Ne laser. Innocula of 1 mm3 of irradiated and non-irradiated tissue were then injected subcutaneously under the right and left flanks of a normal mouse, respectively. The efficacy of the treatment was determined following the growth of the tumor from day 10 after tumor implantation. Under the present conditions a 30% increased efficacy was observed in the case of the explants treated with CY 40 hrs after the last i.p. injection. Porphyrins in the liver and tumor and other tissues of the injected mice were also determined; except for a slight increase in tumor and liver, 40 and 22 hrs after CY i.p. injection respectively, no other changes were observed in any tissue, as compared with not CY treated mice. These results indicate that future treatment, combining the tumor localizing properties of endogenously formed porphyrins from ALA and antineoplasic drugs such as cyclophosphamide, should be encouraged.     

Treatment of onychomycosis and tinea pedis with intermittent itraconazole therapy

A 40-year-old woman had a 10-year history of dermatophyte-related toenail onychomycosis (tinea unguium) and dry-type tinea pedis, which had failed to respond to previous therapy with topical antifungal agents or oral griseofulvin. The patient was successfully treated with four cycles of intermittent itraconazole therapy (that is, 400 mg/d for 1 week per month for 4 months). At the end of this time, the tinea pedis had resolved and the onychomycosis improved significantly after four cycles were completed. Twelve months after the onset of therapy, both conditions had resolved completely according to both clinical and mycologic criteria. Itraconazole was well tolerated, with no side effects reported. These observations suggest that itraconazole intermittent dosing is a highly effective therapy for the treatment of onychomycosis caused by dermatophyte organisms, because it provides a high cure rate after only a short course of therapy.     

Bronchiolitis obliterans with organizing pneumonia in a patient treated with amiodarone]

Bronchiolitis obliterans organizing pneumonia (BOOP) is a well-defined clinicopathological entity. The aetiology of BOOP is generally unknown, although it has been associated with specific diseases or various pharmaceutical drugs. The amiodarone is one of them. We report a patient with BOOP secondary to amiodarone therapy, who presented with cough, fever and sputum production, dyspnoea and night sweats lasting for two months. A chest radiograph showed bilateral patchy and interstitial infiltrates. Lymphocyte phenotyping of bronchoalveolar lavage fluid showed decreased ratio of CD4+:CD8+ lymphocytes. Transbronchial lung biopsy established the diagnosis of BOOP. After stopping amiodarone therapy, symptoms disappeared and the chest radiograph remained normal within two months.     

Bacterial pneumonia associated with corticosteroid therapy in three horses

Three horses developed severe pulmonary infections while being treated with systemic corticosteroids for other diseases. Two of them had an immune-mediated skin disease, compatible with a diagnosis of pemphigus foliaceus, and one had severe chronic obstructive pulmonary disease. Case 1 developed diffuse pneumonia from which Streptococcus zooepidemicus and Bacteroides melaninogenicus were isolated, and it responded to antibiotic therapy. Case 2 developed septicaemia, pulmonary thrombosis and pneumonia associated with Escherichia coli, and died during a peracute illness with signs of disseminated intravascular coagulation. Case 3 developed focal pneumonia from which S zooepidemicus was isolated. This horse was destroyed at the owner's request and no treatment was attempted.