Persistent cutaneous larva migrans due to Ancylostoma species

Cutaneous larva migrans is considered to be a self-limited parasitic infection of about 2 to 8 weeks' duration, though it has been reported to persist for as long as 55 weeks. In this case, a healthy 47-year-old white man had multiple serpiginous lesions typical of cutaneous larva migrans for 18 months. A biopsy taken 2 months before presentation showed a parasite consistent with Ancylostoma species deep in a hair follicle. The patient initially responded to topical thiabendazole, but relapse occurred when therapy was discontinued. Oral thiabendazole cured the problem after 22 months of infestation. Cutaneous larva migrans may sometimes be long-standing, here almost 2 years, even in a healthy patient. Organisms may reside deep in the hair follicles. Topical thiabendazole may not penetrate to this depth, necessitating oral thiabendazole therapy.     

Dirofilaria, visceral larva migrans, and tropical pulmonary eosinophilia

Helminthic infections are prevalent worldwide. The intestinal ascarid, Toxocara, the animal filarial parasite, Dirofilaria, and the human filarial parasite, Wuchereria or Brugia, produce an array of pulmonary disease in humans. Infections are common in temperate, tropical, and subtropical regions of the world. Pulmonary dirofilariasis is essentially an asymptomatic disease. Most cases are diagnosed accidentally after thoracotomy for a solitary pulmonary nodule presumed to be lung cancer. Clinical manifestations of toxocariasis or visceral larva migrans (VLM) are the result of allergic and inflammatory responses of the host, and manifest with airway reactivity, acute pneumonia, and persistent eosinophilia. VLM is a self-limited disease and specific treatment is rarely necessary. In acute cases, a short course of steroids reduces morbidity and mortality but preventive measures are more important in curbing toxocara infection. Tropical pulmonary eosinophilia (TPE) is the result of immunologic hyperresponsiveness to the human filarial antigen and eosinophils play a crucial role in its pathogenesis. Airway hyperreactivity, extreme eosinophilia, and pulmonary physiologic impairment are the characteristic features. Treatment of TPE with diethylcarbamazine results in dramatic amelioration of symptoms. However, low grade inflammation persists in a significant number of patients and can lead to chronic interstitial lung disease. Mass treatment of patients in certain endemic areas has been effective in eliminating TPE.     

Cutaneous larva migrans, sacroileitis, and optic neuritis caused by an unidentified organism acquired in Thailand

The increasingly widespread use of mammographic screening for breast cancer has induced a considerable increase in the number of surgical biopsies. Fine-needle aspiration and microbiopsies can allow to reduce this number. 1) In patients with nodular densities of benign or indeterminate appearance, a negative fine-needle aspiration indicates that no further investigations are needed. In contrast, complete surgical excision is indicated in cases of stellate images. 2) In patients with potentially malignant microcalcifications, fine-needle aspiration is to little value, and microbiopsies should be performed. Indeterminate (type II or III) calcifications are the best indication, since negative microbiopsies may obviate the need for lumpectomy, if the negative predictive value of microbiopsies is sufficiently high in this indication. Focal suspicious microcalcifications (type IV or V) should be removed surgically for both diagnostic and therapeutic purposes. Type IV or V microcalcifications involving a large area of the breast can be investigated by initial microbiopsy; a positive result allows to recommend immediate mastectomy without prior lumpectomy. Fine-needle aspiration and microbiopsies should be performed as part of a multidisciplinary diagnostic strategy involving radiologists, surgeons, cytopathologists, and pathologists. This approach is the only means of improving the management of non palpable mammographic lesions and of reducing the number of unnecessary operation.     

Disseminated infection due to an unusual strain of Nocardia farcinica

Nocardia farcinica, isolated by Nocard in 1888, has recently been redefined as a separate species to asteroides and has been recognised as human pathogen since 1975. Following airborne contamination, lung infection is most usual with frequent dissemination especially to central nervous system. Usually drug resistance makes treatment difficult. The authors describe the first case of Nocardia farcinica disseminated infection in France with lung primarily affection, empyema and encephalitis.     

Cutaneous lesions in patients with visceral leishmaniasis and HIV infection

The authors studied the venous drainage pattern of the stomach in 30 adult laboratory mice (Mus musculus v. alba) and in 31 adult laboratory rats (Rattus norvegicus v. alba) of both sexes. In mice, two basic patterns of the venous drainage of the stomach have been found, the first one (50.0% of cases) with a vena gastroepiploica dextra, while in the second pattern (50.0% of cases) the vena gastroepiploica dextra is absent and the venous blood from the curvatura major ventriculi and fundus ventriculi is drained only via the v. lienalis. In rats, three basic patterns of venous drainage of the stomach were found, the first group (35.2%) with the v. gastroepiploica dextra, the second group (38.4%) with prevalence of the v. gastrica sinistra and the third group with various tributaries of the v. lienalis from the stomach (25.6%). The vena gastrica sinistra is the only constant venous channel in both animals examined. Between interorganic venous anastomoses in the mouse and the rat no great differences exist. In spite of the great variability of veins the results indicate that it is possible to differentiate some basic patterns of the venous drainage of the stomach in the animals studied.     

Secondary membranoproliferative glomerulonephritis due to hemolytic uremic syndrome: an unusual presentation

In vitro selection can be used to generate nucleic acid ligands (aptamers) to target molecules ranging in size and structure from cations to cells. However, the selection process is repetitive and time-consuming. We have automated a protocol for in vitro selection using an augmented Beckman Biomek 2000 pipetting robot. The automated selection procedure requires the integration of four devices and the optimization of four molecular biology methods, and is one of the most complex automated protocols attempted to date. Initial attempts at selection yielded robust replication parasites, but optimization of the automated selection procedure suppressed the emergence of these parasites and led to the selection of true nucleic acid ligands. Automated selection can now be used to generate nucleic acid aptamers in days rather than weeks or months.     

Fistulas are not always due to Crohn''s disease: an unusual groin abscess

A 53-year-old woman with a complete C-7 traumatic quadriplegia developed progressive neurological deterioration, including bulbar symptoms, 3 years after her initial injury. Magnetic resonance imaging showed tethering of the spinal cord at the level of her injury, with marked stretching of the cervical cord associated with medullary and tonsillar herniation. Following transection of the spinal cord, there was some improvement in her condition. Possible etiological factors accounting for this unique presentation are discussed.     

Disseminated invasive infection due to Metarrhizium anisopliae in an immunocompromised child

The first reported human case of possible disseminated infection with the insect pathogen Metarrhizium anisopliae var. anisopliae, a fungus which has been used commercially for biocontrol of insects, is described. The patient, a 9-year-old boy, had a 5-year history of pre-B-cell acute lymphoblastic leukemia and had been on chemotherapy throughout this period. After 10 days of profound neutropenia, lesions consistent with ecthyma gangrenosum appeared on his arms and legs. M. anisopliae was grown from specimens from three separate sites, collected at different times over a period of 1 month: a skin biopsy, a swab from the base of a lesion, and the core of another skin lesion which spontaneously discharged. The initial skin biopsy also showed histological evidence of epidermal necrosis and dermal invasion with fungal hyphae. A computed-tomography (CT) scan of the chest demonstrated a lesion in the superior segment of the lower lobe of the left lung. A CT scan of the brain revealed a lesion in the left temporoparietal region of the brain, consistent with an abscess. Despite antifungal treatment including liposomal amphotericin and 5-flucytosine, the patient eventually died. The initial portal of entry is unknown, but hematogenous dissemination to the skin appears likely because of the multiple ecthymic lesions, and the appearances of the brain lesion on the CT scan are consistent with a hematogenous fungal abscess.     

An unusual route to thermostability disclosed by the comparison of Thermus thermophilus and Escherichia coli inorganic pyrophosphatases

The structures of Escherichia coli soluble inorganic pyrophosphatase (E-PPase) and Thermus thermophilus soluble inorganic pyrophosphatase (T-PPase) have been compared to find the basis for the superior thermostability of T-PPase. Both enzymes are D3 hexamers and crystallize in the same space group with very similar cell dimensions. Two rather small changes occur in the T-PPase monomer: a systematic removal of Ser residues and insertion of Arg residues, but only in the C-terminal part of the protein, and more long-range ion pairs from the C-terminal helix to the rest of the molecule. Apart from the first five residues, the three-dimensional structures of E-PPase and T-PPase monomers are very similar. The one striking difference, however, is in the oligomeric interactions. In comparison with an E-PPase monomer, each T-PPase monomer is skewed by about 1 A in the xy plane, is 0.3 A closer to the center of the hexamer in the z direction, and is rotated by approximately 7 degrees about its center of gravity. Consequently, there are a number of additional hydrogen bond and ionic interactions, many of which form an interlocking network that covers all of the oligomeric surfaces. The change can also be seen in local distortions of three small loops involved in the oligomeric interfaces. The complex rigid-body motion has the effect that the hexamer is more tightly packed in T-PPase: the amount of surface area buried upon oligomerization increases by 16%. The change is sufficiently large to account for all of the increased thermostability of T-PPase over E-PPase and further supports the idea that bacterial PPases, most active as hexamers or tetramers, achieve a large measure of their stabilization through oligomerization. Rigid-body motions of entire monomers to produce tighter oligomers may be yet another way in which proteins can be made thermophilic.     

Autoimmune thrombocytopenic purpura (AITP) and acquired thrombasthenia due to autoantibodies to GP IIb-IIIa in a patient with an unusual platelet membrane glycoprotein composition

The subject (E.B.) is a 63-year-old woman with autoimmune thrombocytopenic purpura (AITP) who was first examined some 6 years ago with symptoms of epistaxis and gum bleeding, severe thrombocytopenia, and large platelets. Her serum tested positively with control platelets in the MAIPA assay performed using monoclonal antibodies (MoAb) to glycoprotein (GP) IIIa (XIIF9, Y2/51), yet was negative in the presence of MoAbs to GP IIb (SZ 22) or to the GP IIb-IIIa complex (AP2, P2). The patient's platelets failed to aggregate with all agonists tested except for ristocetin. IgG isolated from the patient's serum inhibited ADP-induced aggregation of control platelets. Unexpectedly, flow cytometry showed an altered expression of membrane glycoproteins on the patient's platelets. Levels of GP Ib-IX were much higher than previously located by us in platelets. In contrast, the expression of GP IIb-IIIa was about half that seen with control subjects. When Western blotting was performed, a striking finding was a strong band of 250 kDa recognized by a series of MoAbs to GP Ib alpha in addition to the band in the normal position of GP Ib alpha. Finally, ADP-stimulated (E.B.) platelets failed to express activation-dependent epitopes on GP IIb-IIIa as recognized by PAC-1, AP6, or F26 and additionally gave a reduced P-selectin expression after thrombin addition. In conclusion, we present a novel patient with a severely perturbed platelet function where an altered membrane GP profile is associated with the presence of an autoantibody recognizing a complex-dependent determinant on GP IIb-IIIa and inhibitory of platelet aggregation.     

Administration of medications via the intramuscular route: an integrative review of the literature and research-based protocol for the procedure

Administering injections is an activity inherent to nursing practice. A critical review of nursing fundamentals texts found that the "proper" procedure was often non-research based and reflected myths, traditions, and out-of-date recommendations regarding the technique. This article is an integrative review of the extensive research conducted by a variety of researchers in health-related disciplines during the last seven decades. The pertinent research is reviewed and critiqued and serves as the basis for a clinical practice protocol. This research-based procedure ensures efficient and effective nursing care related to intramuscular injections.     

Coagulopathy due to an acquired factor V inhibitor and subsequently thrombosis

One hundred and fifteen term pregnancies (62 normal pregnancies, 53 high risk pregnancies) were observed by umbilical artery Doppler velocimetry (UmA S/D ratio) and antenatal fetal heart rate monitoring (NST), and 37 of them were also observed by umbilical artery blood-gas analysis at birth. We compared the effects of these three methods to predict the neonatal outcome. The standards of the neonatal poor outcome were 5-min Apgar score < or = 7 and/or a birth weight < 2500g (SGA). The results were: (1) The neonatal poor outcome were more frequently observed in the abnormal UmA S/D ratio (> or = 3.0) group and in the UmA pH < or = 7.2 group (P < 0.005, P < 0.025, respectively), but there was no significant difference between the NST reactive or nonreactive groups (P > 0.05); (2) The neonatal acidosis at birth was also associated with the abnormal UmA S/D ratio (> or = 3.0); (3) The sensitivities of UmA S/D ratio, UmA pH, NST to predict the 5-min Apgar score < or = 7 were 60.0%, 60.0%, 20.0% respectively; the specificities 84.6%, 81.3%, 81.8% respectively. And their sensitivies to predict SGA were 100.0%, 100.0%, 40.0% respectively; the specificities 86.4%, 80.0%, 82.7% respectively. Our data show that UmA S/D ratio and UmA pH are better than NST in the prediction of neonatal outcome, and the abnormal UmA S/D ratio is closely associated with neonatal acidosis at birth.