Leucocytoclastic vasculitis in a patient with azathioprine hypersensitivity

We report the case of a 77-year-old man admitted nine days after being commenced on azathioprine with symptoms initially thought to be secondary to sepsis but in fact due to azathioprine hypersensitivity. He developed histologically proven cutaneous leucocytoclastic vasculitis following the re-introduction of azathioprine. We review the literature concerning adverse reactions to azathioprine and the problems of making the diagnosis as well as highlighting azathioprine as a novel cause of leucocytoclastic vasculitis.     

Iodine-131-anti-B1 radioimmunotherapy for B-cell lymphoma

PURPOSE: The CD20 B-lymphocyte surface antigen expressed by B-cell lymphomas is an attractive target for radioimmunotherapy, treatment using radiolabeled antibodies. We conducted a phase I dose-escalation trial to assess the toxicity, tumor targeting, and efficacy of nonmyeloablative doses of an anti-CD20 monoclonal antibody (anti-B1) labeled with iodine-131 (131I) in 34 patients with B-cell lymphoma who had failed chemotherapy. PATIENTS AND METHODS: Patients were first given tracelabeled doses of 131I-labeled anti-B1 (15 to 20 mg, 5 mCi) to assess radiolabeled antibody biodistribution, and then a radioimmunotherapeutic dose (15 to 20 mg) labeled with a quantity of 131I that would deliver a specified centigray dose of whole-body radiation predicted by the tracer dose. Whole-body radiation doses were escalated from 25 to 85 cGy in sequential groups of patients in 10-cGy increments. To evaluate if radiolabeled antibody biodistribution could be optimized, initial patients were given one or two additional tracer doses on successive weeks, each dose preceded by an infusion of 135 mg of unlabeled anti-B1 one week and 685 mg the next. The unlabeled antibody dose resulting in the most optimal tracer biodistribution was also given before the radioimmunotherapeutic dose. Later patients were given a single tracer dose and radioimmunotherapeutic dose preceded by infusion of 685 mg of unlabeled anti-B1. RESULTS: Treatment was well tolerated. Hematologic toxicity was dose-limiting, and 75 cGy was established as the maximally tolerated whole-body radiation dose. Twenty-eight patients received radioimmunotherapeutic doses of 34 to 161 mCi, resulting in complete remission in 14 patients and a partial response in eight. All 13 patients with low-grade lymphoma responded, and 10 achieved a complete remission. Six of eight patients with transformed lymphoma responded. Thirteen of 19 patients whose disease was resistant to their last course of chemotherapy and all patients with chemotherapy-sensitive disease responded. The median duration of complete remission exceeds 16.5 months. Six patients remain in complete remission 16 to 31 months after treatment. CONCLUSION: Nonmyeloablative radioimmunotherapy with 131I-anti-B1 is associated with a high rate of durable remissions in patients with B-cell lymphoma refractory to chemotherapy.     

Meniscal repair using the inside-to-outside technique

The frequent occurrence of degenerative joint disease following complete or partial meniscectomy is well recognized. Meniscal repair has been shown to lead to a lower prevalence of degenerative changes in the knee. Arthroscopically assisted inside-to-outside meniscal repair is a safe, reproducible technique for for salvaging the torn meniscus.     

Parkinson's disease in populations of African origin: a review

Several studies have reported a lower prevalence of Parkinson's disease (PD) in populations of African origin than in populations of European origin, raising the possibility that the former are protected against PD. However, the confounding effects of low case ascertainment and high selective mortality on PD prevalence estimates in populations of African origin cannot be ruled out at this time. One hypothesis consistent with available data is that populations of African origin are vulnerable to vascular parkinsonism, which is associated with high mortality.     

Possible reasons for the variability of human responses to IAC-CPR

OBJECTIVE: To propose reasons for the variability of the hemodynamic responses and survival data observed when interposed abdominal compression cardiopulmonary resuscitation (IAC-CPR) is performed on humans in cardiac arrest. METHODS: Critical content review of all studies performed in the United States examining IAC-CPR in humans and of selected animal studies addressing hemodynamic mechanisms of CPR. Articles in the English language dealing with human IAC-CPR studies from 1970-1993 were retrieved using the MEDLINE database of the National Library of Medicine. RESULTS: IAC-CPR does not consistently improve coronary perfusion pressure (CPP) over standard CPR in humans and is capable of decreasing as well as increasing CPP. This variability does not seem dependent on the manner in which abdominal compressions are performed. Because of the limited response to standard CPR, significant increases in return of spontaneous circulation would be expected with IAC-CPR if a large percentage of patients were to have favorable increases in CPP. However, other patients may be adversely affected by decreases in CPP during IAC-CPR, with unsuccessful resuscitation of those individuals. Return of spontaneous circulation also may be enhanced using IAC-CPR due to other factors reflected in the initial arrest rhythm and in arrest-population demographics. CONCLUSION: IAC-CPR should not be recommended for routine use until the mechanism of its beneficial effects is known and until those patients who are likely to benefit from the technique can be better identified.     

Effects of intravenous medium-chain triglycerides on pulmonary gas exchanges in mechanically ventilated patients

OBJECTIVE: In mechanically ventilated patients, pulmonary gas exchange was investigated during the administration of total parenteral nutrition containing medium-chain triglycerides or long-chain triglycerides as fat emulsions. DESIGN: Prospective, randomized, crossover trial (two lipid infusion periods of 8 hrs). SETTING: Intensive care unit in a university hospital. PATIENTS: Six mechanically ventilated patients, using the pressure-support mode. INTERVENTIONS: Total caloric intake was adapted according to measured energy expenditure. Fat emulsion provided 50% of the energy expenditure. Patients were infused with 50% medium-chain/50% long-chain triglycerides or 100% long-chain triglycerides in a random sequence. MEASUREMENTS AND MAIN RESULTS: Oxygen consumption, CO2 production, and minute ventilation were measured by indirect calorimetry. PaO2 and PaCO2 were determined in blood samples. Medium-chain triglycerides increased oxygen consumption by 27.8% and minute ventilation by 14.3% at the end of the protocol. CO2 production, PaO2, and PaCO2 were not different between groups. CONCLUSIONS: Medium-chain triglycerides cause an increase in metabolic demand in mechanically ventilated patients when they are infused over a short period. Postoperative or intensive care unit patients with a low pulmonary reserve should receive infusions of medium-chain triglycerides over a more prolonged period than long-chain triglycerides.     

Fibular shortening in poliomyelitis

We have determined the nucleotide and encoded amino acid sequences of the capsid, membrane precursor, membrane, envelope, and nonstructural NS1 protein genes of a dengue-2 virus (D2-04) isolated from a patient in Hainan, China. The sequenced region contains a gene organization similar to that of other flaviviruses. The overall amino acid sequence similarity between D2-04 and other dengue-2 viruses is greater than 92%, whereas that between D2-04 and members of the other dengue serotypes is about 65%.     

Novel naphthoquinones from Conospermum incurvum

During the reisolation of the trimeric naphthoquinone derivative conocurvone [1] from an extract of the Australian shrub Conospermum incurvum, six monomeric naphthoquinones were isolated. These include three novel 1,4-naphthoquinone derivatives: 3-methyl-14,15-dihydro-15-hydroxyteretifolione B [3], 3-methyl-14,15-dihydro-15-hydroxyteretifolione B methyl ether [4], and 2,3-dimethyl-6-hydroxy-7-methoxy-1,4-naphthoquinone [5]. In addition, the previously reported compounds 3-methylteretifolione B [6], 3-methylteretifolione B methyl ether [7], and 8-geranyl-2,7-dihydroxy-3-methyl-1,4-naphthoquinone [8] were isolated and identified. The structures of the novel 1,4-naphthoquinones were elucidated by spectral methods. While conocurvone [1] is a potent inhibitor of HIV-1-induced cell killing, all of the monomeric naphthoquinone derivatives were inactive against HIV-1.     

Radiation-induced temporary epilation after a neuroradiologically guided embolization procedure

A 34-year-old woman underwent embolization of a left paraorbital arteriovenous malformation guided with a bi-plane x-ray system in two sessions separated by 3 days. Imaging included 110 minutes of fluoroscopy and 46 digital subtraction angiography acquisitions. Entrance skin dose rates were determined with measurements performed on a skull phantom. The maximum possible skin dose was estimated to be 6.6 Gy, which is consistent with the temporary epilation in the right occipital region of the skull reported by the patient approximately 5 weeks later.     

Primary lung cancer in patients under 40 years of age

There seems to be a resistance of patients and physicians towards aggressive diagnostic evaluation of the symptoms of lung cancer in young people. We here review nine series of young patients with primary lung cancer. Patients below 40 years of age represent between 1.2 and 5% of the total lung cancer population. The distribution of sex and histopathologic findings is different, there being more women, fewer cases of squamous cell and more cases of small anaplastic and adenocarcinoma in the young group. Between 87 and 96% are smokers. There is a delay from the debut of symptoms to the first contact with a general physician of 2.4 to 10.8 months. There is a wide variation concerning tendency to operate with a frequency of curative resection of between 15 and 57%. Based on the survival of young patients who are treated by curative surgical resection, the outcome of surgical treatment for young patients does not differ from the general experience concerning resection in patients of all ages. Young patients who are found inoperable have worse survival than the older patients. Seventy to 90%, more than in the group of patients of all ages, have stadium II or III at the time of diagnosis. In conclusion, physicians should be aggressive with respect to the diagnostic evaluation even of young patients with symptoms suggestive of lung cancer.