Alpha-interferon-induced arthritis: clinical presentation treatment, and prevention

Carotenoid interactions during absorption and in postabsorptive metabolism have been observed in both human and animal studies. We reviewed the mutual interactions reported between lutein and beta-carotene and report new data on the postprandial beta-carotene and retinyl ester response in the triglyceride-rich plasma lipoprotein (TRL) fraction in volunteers after a single test meal with beta-carotene alone, or beta-carotene combined with lutein or lycopene. Results indicate an inhibitory effect of lutein on beta-carotene absorption, but apparently not on beta-carotene cleavage. In a comparative study with two beta-carotene/lutein ratios (2:1 and 1:2, respectively), this inhibitory effect of lutein was found to be most marked when lutein was the predominant carotenoid. In studies on plasma (serum) response also an inhibitory effect of beta-carotene on lutein response was observed.     

Varicella-zoster virus: infection, control, and prevention

Varicella-zoster virus is a herpes virus that produces a primary infection, chickenpox, manifested by a vesicular eruption and is considered one of the common childhood infectious diseases. After the initial infection the virus becomes latent, then when activated it is manifested as herpes zoster, commonly known as shingles. This highly communicable human disease is associated with serious morbidity and significant mortality, particularly among the immunocompromised. When introduced in the hospital, significant disruptions occur and serious sequelae may results. Recently, a live virus varicella vaccine was approved by the Food and Drug Administration in the United States. Studies have shown the vaccine to be safe and effective. Widespread use of this vaccine may be beneficial in reducing the opportunities for varicella-zoster virus introductions in health care settings.     

Tuberculosis 1992: current clinical aspects, epidemiology and diagnosis

We review four different aspects of tuberculosis (TB), a disease which is making a comeback as a focus of medical attention. The diagnosis of TB in HIV infected individuals can be very challenging for the clinician and an increased number of side effects complicates treatment. Updated information in this area appears necessary for physicians who are in charge of HIV-infected patients. The "cursed duet" of TB and HIV infection is also responsible for the increase of TB in subsaharan Africa. Recent data are discussed in relation to this issue. Another problem for developing countries is the diagnosis and treatment of children's TB, which involves particular features as compared to the adult form of the disease. Finally, new diagnostic methods are now available from the laboratory. The detection of mycobacteria with the polymerase chain reaction has proven very useful in the diagnosis of tuberculous meningitis. Detection of tuberculostearic acid and mycobacterial antigen also represent important advances. The role of these techniques in the diagnosis of TB forms other than meningitis will need to be defined in the near future.     

The watermelon stomach: clinical presentation, diagnosis, and treatment

The watermelon stomach syndrome is an increasingly recognized cause of persistent acute or occult gastrointestinal bleeding, typically in elderly women. This disorder often presents with severe iron deficiency anemia, and a variety of associated conditions including autoimmune disease, cirrhosis, achlorhydria, and hypochlorhydria. Diagnosis is made by the characteristic endoscopic appearance of visible linear watermelon-like vascular stripes in the antrum. Histology confirms the vascular nature of this disorder, showing dilated and thrombosed capillaries in the lamina propria, associated with reactive fibromuscular hyperplasia. The optimum treatment of choice is not known. Several treatment options, including surgical antrectomy, and endoscopic photocoagulation with Nd:Yag laser, heater probe therapy, and bipolar electrocautery, have yielded excellent results. Pharmacological agents have also been used to treat selected numbers of patients, most of which comprise a small number of case reports.     

Hantavirus pulmonary syndrome: epidemiology, prevention, and case presentation of a new viral strain

Hantavirus pulmonary syndrome (HPS) is a viral infection from a new strain of Hantavirus. The Hantavirus was first discovered in North America in 1993 after an outbreak of fatal illness on a Navajo Indian reservation in New Mexico. Since then, 122 cases of HPS (with a high mortality rate of more than 50%) have been reported in 23 states, with the highest prevalence in the Four Corners area. The reservoir for Hantavirus is small rodents, mostly field mice, vole, and chipmunks. It is transmitted through inhalation of airborne virus from dry rodent excreta and saliva. A North American strain of Hantavirus, named ain nombre virus (SNV), primarily affects the lungs, causing rapid accumulation of fluids and leading to noncardiogenic pulmonary edema, pleural effusion, and acute respiratory distress syndrome (ARDS). In the prodromal stage, HPS presents with flu-like symptoms, nausea, vomiting, and gastrointestinal pain and is often mistaken on the first visit for other infectious diseases or gastroenteritis. In the second acute stage, rapid respiratory deterioration begins: HPS is often misdiagnosed for pneumonia, idiopathic ARDS, and pulmonary edema. HPS treatment with an experimental antiviral intravenous drug, ribavirin, is under investigation. Practitioners must possess through clinical knowledge on the diagnoses, pathology, treatment, and course of the disease to reduce the mortality and morbidity rate of this rare but serious infection. A case report based on a recent HPS death in New York State on Long island in April 1995 is presented.     

Dengue virus infection of human T lymphocytes

A 39-year old male patient was admitted to the University Hospital of the Faculty of Medicine of Ribeir?o, Preto with signs and symptoms of sudden dyspnea, generalized myalgia and behavioral disorders. The initial suspicion was alcohol abstinence syndrome and the patient was referred for psychiatric and neurologic care. The evolution of the patient with a worsening of signs and symptoms, presence of crises of tachypnea, agitation, difficulty to swallow, irritability and hydrophobia, and his report of having been bitten by a suspected dog raised the hypothesis of rabies. The diagnosis was confirmed by examination of a corneal impression, biological tests in the cerebrospinal fluid (CSF) and saliva and visualization of Negri bodies in nervous tissue (direct immunofluorescence). The patient evolved with agitation, aggressiveness, and worsening tachypnea intercalating with apnea, and died on the 4th day after admission.     

Vascular dementia: a contemporary review of epidemiology, diagnosis, prevention, and treatment

The past decade has seen a renewed interest in vascular dementia. Key epidemiologic studies have examined the prevalence, incidence, course and risk factors of vascular dementia. New classification systems have been developed to improve the reliability of the diagnosis, and there have been advances in diagnostic methodology, such as neuroimaging and neuropsychological assessment. New treatments for vascular dementia are being developed to protect the brain from cerebral ischemia and to limit progression of cognitive impairment. Diagnostic criteria for vascular dementia remain to be validated by carefully designed, systematic, clinicopathologic study. Once such criteria are validated, meaningful study of subgroups of vascular dementia can be explored. Until the relationship between vascular dementia and Alzheimer's disease is better defined, the nosology for vascular dementia may be defined best as dementia associated with stroke.     

Multiple system atrophy: clinical presentation and diagnosis

Multiple system atrophy (MSA) describes a relatively uncommon, debilitating disorder that is frequently misdiagnosed as Parkinson's disease. Patients with MSA show various combinations of parkinsonism, cerebellar ataxia, pyramidal signs and progressive autonomic failure, especially cardiovascular and urologic autonomic dysfunction. Few treatment options exist. Although some patients initially respond well to dopaminergic treatment for their parkinsonian symptoms, striatal degeneration occurs, and levodopa often becomes ineffective. Thus, physicians may provide only symptomatic treatment and support for patients with MSA. In this paper, we present a case study of a 68-year-old woman who came to the Vanderbilt Movement Disorders Clinic with severe autonomic dysfunction and parkinsonism, previously diagnosed as Parkinson's disease. Following autonomic function tests as well as clinical evaluation, she was diagnosed with MSA and began treatment for orthostatic hypotension and micturition dysfunction.     

Catheter-related infection: an update on diagnosis, treatment, and prevention

PURPOSE: Neoadjuvant chemotherapy is becoming the standard of care for locally advanced breast cancer. This study was performed to determine whether pathologic primary tumor response to neoadjuvant chemotherapy might predict axillary lymph node status and so be used to identify patients in whom surgery could be effectively limited to biopsy of the previous primary tumor site without axillary dissection. PATIENTS AND METHODS: Between 1992 and 1996, 170 consecutive patients with locally advanced breast cancer were treated in a prospective trial with four preoperative cycles of 5-fluorouracil, doxorubicin, and cyclophosphamide. Disease was staged before initiation of preoperative chemotherapy and before surgery. Segmental resection with axillary lymph node dissection or modified radical mastectomy was performed first, followed by postoperative chemotherapy and radiation therapy of the breast (or chest wall) and regional lymphatics. Patient and tumor characteristics associated with complete versus incomplete pathologic primary tumor response to neoadjuvant chemotherapy and correlation between primary breast tumor pathologic response and axillary lymph node status found at surgery were analyzed. RESULTS: Of 156 evaluable patients, 30 patients (19%) had primary breast tumors that were completely eliminated after induction chemotherapy based on histologic assessment. Nineteen of those 30 patients (63%) had negative axillary lymph nodes at dissection, compared with 13 patients (33%) of the 40 who had a near-complete pathologic primary tumor response (< or = 1 cm3 remaining) and only 15 patients (17%) of the 86 who had > 1 cm3 tumor remaining in the pathology specimen of the breast primary. Of the 22 patients with a complete pathologic response in the breast and a clinically negative axilla after induction chemotherapy, axillary dissection revealed positive lymph nodes in four. These four patients had only one or two positive lymph nodes. DISCUSSION: Because initial clinical regression of primary tumor with neoadjuvant chemotherapy is considered an excellent prognostic indicator and because patients with locally advanced breast cancer routinely receive local and regional radiation treatment followed by additional chemotherapy, the role of breast and axillary surgery has been questioned. In this study, a complete pathologic response of the primary tumor to induction chemotherapy is highly predictive of negative axillary lymph node status. Therefore, axillary lymph node dissection may be omitted in certain subsets of patients who have a biopsy-proven complete pathologic response in the primary tumor and a clinical negative axillary examination. Further prospective, randomized investigation is needed to confirm this finding.     

Oral hairy leukoplakia: clinicopathologic features, pathogenesis, diagnosis, and clinical significance

Oral hairy leukoplakia (OHL) is a lesion frequently, although not exclusively, observed in patients infected by human immunodeficiency viruses (HIV). OHL is clinically characterized by bilateral, often elevated, white patches of the lateral borders and dorsum of the tongue. Histologically, there is profound acanthosis, sometimes with koilocytic changes, and a lack of a notable inflammatory infiltrate. The koilocytic changes are due to intense replication of Epstein-Barr virus (EBV), while epithelial hyperplasia and acanthosis are likely to result from the combined action of the EBV-encoded proteins, latent membrane protein-1, and antiapoptotic BHRF1. How OHL is initiated and whether it develops after EBV reactivation from latency or superinfection remain unresolved; nevertheless, definitive diagnosis requires the demonstration of EBV replicating vegetatively in histological or cytological specimens. In patients with HIV infection, the development of OHL may herald severe HIV disease and the rapid onset of AIDS, but despite its title, OHL is not regarded as premalignant and is unlikely to give rise to oral squamous cell carcinoma.     

Sudanese mucosal leishmaniasis: epidemiology, clinical features, diagnosis, immune responses and treatment

The epidemiology, clinical features, pathology, immune responses, diagnosis and treatment of 14 patients with mucosal leishmaniasis in the Sudan are described. The condition occurred mainly in adult males, particularly in certain closely related tribes from the western Sudan. It affected the mucosa of the upper respiratory tract and/or the oral mucosa and sometimes followed treated kala azar. The parasites were sometimes confined to the mucosa, sometimes spread to the lymph nodes, and rarely infected the bone marrow and spleen. One of the 2 patients with both visceral and mucosal leishmaniasis differed from classical kala azar cases; his infection was longer lasting, he was leishmanin positive, and his peripheral mononuclear cells proliferated in response to leishmanial antigens. Mucosal leishmaniasis following treated kala azar is a similar phenomenon to post-kala azar dermal leishmaniasis and post-kala azar uveitis. Post-kala azar mucosal leishmaniasis can therefore be added to the other post-kala azar leishmanial infections. Using the polymerase chain reaction, Southern blot analysis with specific probes, and isoenzyme characterization, the causative parasite was identified as Leishmania donovani in 4 patients and as L. major in one. Unlike American mucocutaneous leishmaniasis, mucosal leishmaniasis in the Sudan was not preceded or accompanied by cutaneous lesions and the response to pentavalent antimony or ketoconazole was good.     

Bronchiolitis obliterans: pathogenesis, prevention, and management

Increasing early success-post lung transplant has been tempered by the long-term development of histologic bronchiolitis obliterans (OB) or of the progressive airway obstruction which is called bronchiolitis obliterans syndrome (BOS). Multiple lines of evidence suggest that OB/BOS is due to an injury directed against the epithelial cells in the airways of the donor lung by the immune system of the recipient. Acute rejection is the strongest risk factor for the subsequent development of this process. Efforts to prevent or minimize acute rejection may reduce the prevalence of OB/BOS. Results of treatment with augmented immunosuppression have been disappointing but the treatment of complicating infections in the allograft can be beneficial. Multicenter studies are needed to assess the efficacy of new immunosuppressive agents in preventing or treating OB/BOS.     

Gastric motor dysfunction in diabetic patients: pathogenesis, clinical manifestations, diagnosis and treatment

Recent reports provide evidence, that the disordered gastric motoric function in diabetic patients depends on glycaemia and that it can influence metabolic control. The etiopathogenesis of disordered gastric motoric function is poorly understood and is mainly hypothetical. The diagnosis of this dysfunction is difficult. It is recommended to evaluate of gastric motility, especially by scintigraphy, manometry and electrogastrography. In the treatment, it is important to remember about the good metabolic control of diabetes and use the gastrokinetic drugs in the combination or alternating therapy. In especially severe cases, surgical therapy is indicated. Lack of effective method of gastric motoric dysfunction treatment in diabetic patients suggest the necessity of further studies on new drugs, which would normalise the motoric abnormality and eliminate the symptoms.     

Ovarian cancer: epidemiology, diagnosis, and management

Ovarian cancer is a common malignancy for which no widely effective prevention or early detection strategies are known. It is one of the most responsive of adult solid tumors, however, and patients can be cured by appropriately applied regimens of surgery, radiation, and chemotherapy. Expertise is required to select and coordinate the appropriate combinations. Therapeutic trials are underway at various centers, including the Medicine Branch of the NCI, to develop new treatment strategies and refine existing modalities.