Listeria-associated pericarditis in an AIDS patient

Listeria monocytogenes is a pathogenic, facultative intracellular gram-positive rod, generally seen in cell-mediated immunocompromised states. In acquired immunodeficiency syndrome (AIDS), it most commonly presents as bacteremia or meningitis. An association with pericarditis has not been described previously in this group of patients. This article describes a case of pericarditis secondary to listeriosis involving a focal pancarditis and necrosis of the A-V node with subsequent refractory ventricular tachyarrhythmias in an immunodeficient patient presenting with altered mental status. Infectious etiologies should be considered for "benign" appearing pericardial effusions in AIDS patients and the diagnosis of listeriosis excluded in the presence of "diphtheroid-like" organisms.

[The circadian profile of ventricular extrasystole]

STUDY OBJECTIVE

to determine the existence of circadian variability (CV) of single ventricular premature beats (VPBs) and study its relationship with the heart rate variation; to compare sub-groups of patients (Pts) with and without antiarrhythmic therapy and with ischemic cardiopathy versus a free structural cardiopathy group.

DESIGN

retrospective study.

PATIENTS AND METHODS

the CV of VPBs was analyzed by Holter monitoring in 147 Pts, 93 male and 54 female with a mean age of 59 +/- 14.6. Seventy seven Pts were not taking antiarrhythmic drugs while 70 were doing it: Amiodarone 23, Propafenone 30, B-Blockers 9, Quinidine and Disopyramide 7, Flecainide 1. Sixty five Pts had ischemic cardiopathy and 37 were free of any structural abnormality. The selection criteria consisted in: 1--more than 100 VPBs/24h; 2--distribution over more than 12 hours; 3--absence of any hour with more than 35% of the total VPBs in the recording. Data were presented in a percentage form and the results evaluation was made by using single and two-harmonic regression models.

MAIN RESULTS

a CV was found to the single VPBs, with minimum values during the nocturnal period and maximum values in the morning, with a significant adjustment to the two-harmonic regression model, defined by the equation y = 4.2 - Q,559 sen (2 pi T/24) - 0.604 cos (2 pi T/24) - 0.417 sen (4 pi T/24) + 0,272 cos (4 pi T/24) (p < 0.001). A strong positive correlation was observed between VPBs and heart rate variability (r = 0.95; p < 0.001). The sub-groups of Pts, whether taking antiarrhythmic drugs or not, also showed a CV with a statistically significant two-harmonic regression pattern, with a major morning increase of VPBs in the antiarrhythmic group. The free structural cardiopathy sub-group displayed a best adjustment to the single harmonic regression model while the ischemic group exhibited a two-harmonic regression pattern.

CONCLUSIONS

a significant circadian variability of VPBs with a bi-modality expression was determined. The majority of the analyzed sub-groups showed the same kind of variation. A strong positive correlation with the heart rate variability was observed.

HIV-1- prevalence among drug deaths in major cities of central and northern Europe

Since 1985, a number of Institutes of Forensic Medicine in Germany have cooperated in a multicenter study, to provide a constant monitoring of HIV-1-prevalence among drug related deaths. In 1990/91, the Institutes in Copenhagen, Stockholm, Vienna and Zürich also participated in this study. HIV-1-prevalence is decreasing in the German cities, whereas the epidemiological development is not uniform in the other major cities. Regional differences are obvious. In 1991, the prevalence rates were as follows: Berlin 15% (n = 220), Hamburg 4% (n = 179), Frankfurt 17% (n = 167), Munich 9% (n = 136), Stockholm 10% (n = 79), Copenhagen 14% (n = 130), Vienna 20% (n = 56), and Zürich 23% (n = 84).

[Muscular dystrophy as a risk factor in anesthesia]

Three cases of muscular dystrophy are reported on (8 years, 4 months, 10 months) in which serious conditions arose under anaesthetic (bradycardia, asystolia, hyperkalemia, rising CPK). In the first two cases there was no way of avoiding a fatal outcome, but in the third case the child survived with no permanent damage. The cause of incidents of this kind is discussed first as being hyperkalemia due to acute rhabdomyolysis, and secondly malign hyperthermia. There were no indications of malign hyperthermia in this case. It is hardly possible to distinguish this in an acute clinical ward, as the clinical symptoms are very similar. If it is known that muscular dystrophy is present, depolarising relaxants should be given sparingly. This also applies, as the first case shows, for muscular dystrophy of the Becker type, which can on the whole be regarded as benign in comparison with progressive muscular dystrophy of the Duchenne type. In this instance a forensic and anaesthetic expert's opinion even had to be produced at the request of the Public Prosecutor. The post mortem was carried out under the heading of a possible "mistaken medical treatment" but there was no evidence to justify such an assumption.

Genotype/phenotype association in cystic fibrosis: analyses of the delta F508, R553X, and 3905insT mutations

A striking clinical phenomenon of cystic fibrosis is the heterogeneous disease expression. It must therefore be assumed that the nature of the mutations associated with cystic fibrosis might partly determine the phenotypic manifestations. The relation between the cystic fibrosis mutations delta F508, R553X, and 3905insT and clinical parameters such as sweat test electrolytes, age at chronic Pseudomonas aeruginosa colonization, Chrispin-Norman x-ray scores, and relative underweight have been investigated in 45 patients homozygous for delta F508 (delta F2), in 12 compound heterozygotes for delta F508/R553X (delta F1/RX1), in three R553X homozygotes (RX2), and in 13 patients compound heterozygous for delta F508/3905insT (delta F16). We have found significant differences between the genetically defined subgroups concerning the mean age at onset and the cumulative incidence of chronic P. aeruginosa colonization and Chrispin-Norman x-ray scores. The significant results as well as some trends regarding the relative underweight demonstrate a milder clinical course in R553X heterozygotes and more severe disease in the delta F16 group compared to delta F508 homozygotes. The three patients homozygous for R553X presented with a two-stage course showing mild progression before P. aeruginosa infection and as severe a course as the delta F16 patients after P. aeruginosa colonization at the age of 12 y. The findings presented here indicate that specific mutations can influence the severity and progression of the disease, implicating the importance of mutation and haplotype analyses. However, wide variations within the genetically homogeneous subgroups illustrate that other determinants of the clinical status do exist.

Countermeasures against space flight related bone loss

This paper reviews human data concerning bone loss and attempted countermeasures during spaceflight and bed rest, a commonly employed technique to simulate the effects of weightlessness on the musculoskeletal system.

[Inflammatory cancer of the breast. Therapy and follow-up]

Inflammatory carcinoma has the highest mortality rate amongst the locally progressed cancers of the female breast. To define it, clinical, pathological and biological criteria have to be considered. The crucial finding is tumour-cell embolism in the subdermal lymphatics of the affected breast. 30 patients with inflammatory breast cancer were treated with three different concepts of therapy. In the first group, initial surgery (mastectomy with axillary dissection) was followed first by 6 cycles of chemotherapy, then by radiation of the thoracic wall, axilla and supraclavicular lymph nodes. The second concept included primary chemotherapy (6 cycles) with mastectomy/axillary dissection after the second or third cycles. In the third group, primary radiation of breast and axilla was performed, followed by 6 cycles of chemotherapy. From all three groups, 9 patients showed receptor-positive tumours; additional tamoxifen therapy (if postmenopausal) or GNRH-analogues (if premenopausal) were given. None of the three therapy managements could improve the average time of survival. Only the patients with hormonal therapy showed a better prognosis, which might well have been the result of a higher differentiation of the tumour. The study proves, that our efforts in therapy have so far been insufficient. Mastectomy, in particular as a psychically traumatizing procedure, fails to improve the patient's prognosis. It might regain its importance, when new, satisfactory methods of therapy of the systemic disease "inflammatory breast cancer" have been found. It is still uncertain, whether better prognosis can be achieved by a treatment with GNRH-analogues.

Argon laser laparoscopy: an effective technique for conservative treatment of unruptured ectopic pregnancy

Between October 1987 and January 1990, 60 patients with unruptured ectopic pregnancy in the ampullary portion of the tube were treated with linear salpingotomy, using the argon laser laparoscopically. In all cases, salpingotomy was performed by the "bare-fiber" technique, with a power of 3-6 watts. The same fiber was used for incision and coagulation either with a contact or a non-contact technique. There were no instrument-related intra- or postoperative complications. Twenty-four patients were evaluated by second-look laparoscopy or hysterosalpingography for tube patency and possible formation of adhesions. In all of these patients the tubes were patent. In one patient, the tube failed to close, resulting in a fistula. Four patients had filmy adhesions, covering the tube near the incision site. There were no adhesions covering the distal part of the tube.

Determining consanguinity by oligonucleotide fingerprinting with (GTG)5/(CAC)5

Simple tandemly organized (GTG)n/(CAC)n sequences are spread throughout the human chromosomes. The most informative DNA fingerprints for the testing of pedigrees and/or paternity were obtained with the simple triplet repeat probe (GTG)5 or its complement (CAC)5. These hypervariable simple-repeat fragments are stably inherited in a Mendelian fashion. Using these highly discriminating probes, all human individuals could, theoretically, be differentiated, except for genetically identical monozygotic twins. Examples from actual case work are reported and pertinent advantages of this methodology are discussed.

[Magnetic resonance tomographic screening studies of the bone marrow with gradient echo sequences: (I) the contrast relations of phase-identical and phase-shifted gradient echo sequences. Studies on probands and pathological-anatomical preparations]

Anatomical specimens and normal persons were studied by gradient echo MR imaging to determine the influence of different echo times (TE) on bone marrow contrast. First of all, six normal persons were studied to determine specific echo times for in-phase and opposed-phase states. Using different sequences bone marrow contrast in isolated femoral bones was determined and compared to results of pathological exams. Red bone marrow had no signal on opposed-phase images; contrast between red and yellow marrow was higher on opposed-phase than on in-phase images. Bone marrow lesions can be expected to be visualised with high signal on opposed-phase images; this technique should be especially suited for MR imaging of bone marrow.

Individual-specific DNA fingerprinting in man using the oligonucleotide probe (GTG)5/(CAC)5

Restriction fragment length polymorphisms (RFLPs) associated with interspersed simple repetitive DNA arise from DNA fragment lengths that contain variable numbers of the repeated motifs. Using restriction enzymes with different 4 base pair recognition sites and the simple triplet repeat hybridization probe, (GTG)5/(CAC)5, DNA multilocus fingerprints can be obtained in man. Only the DNAs of monozygous twins show indistinguishable banding patterns. Since the bands are inherited according to Mendelian laws, DNA fingerprints can be used for identification of individuals and paternity analysis. The discriminatory power in the DNA fingerprinting technique in forensic science is demonstrated and examples of paternity testing are given.

[Late fatality after CO poisoning]

The report involves a 57-year-old man who was released from in-patient treatment relatively free of complaints 3 days after an attempted suicide with carbon monoxide. After a trouble-free interval, however, more and more organic brain symptoms accompanied by spasms appeared. In the end, the patient died 2 months later of an intermittent fulminating terminal embolism of the pulmonary artery with a thrombosis in the veins of the lower extremities. The clinical course and the anatomicopathological findings are discussed from the pathophysiological point of view. The question of a causal relationship between the "attempted suicide and lethal outcome" had to be answered in the affirmative as regards the insurance law aspects.

Can the adult skeleton recover lost bone?

The loss of bone mineral with aging and subsequent development of osteoporosis is a common problem in elderly women, and as life expectancy increases, in elderly men as well. Space flight also causes bone loss and could be a limiting factor for long duration missions, such as, a Mars expedition or extended occupation of a space station. Before effective countermeasures can be devised, a thorough knowledge of the extent, location, and rate of bone loss during weightlessness is needed from actual space flight data or ground-based disuse models. In addition, the rate and extent that these losses are reversed after return from space flight are of primary importance. Although the mechanisms are not likely to be the same in aging and space flight, there are common elements. For example, strategies developed to prevent disuse bone loss or to enhance the rate of recovery following space flight might have direct applicability to clinical medicine. For various reasons, little attention has been given to recovery of bone mass following space flight. As a prelude to the design of strategies to enhance recovery of bone, this paper reviews published literature related to bone recovery in the adult. We conclude that recovery can be expected, but the rate and extent will be individual and bone site dependent. The development of strategies to encourage or enhance bone formation following space flight may be as important as implementing countermeasures during flight.

Prevalence of human papillomavirus genomes in tissues from the lower genital tract as detected by molecular in situ hybridization

Incidence cases of human papillomavirus (HPV)-related disease of the lower anogenital tract were prospectively collected and submitted to RNA-DNA in situ hybridization, which allows a direct correlation between morphology and the presence of viral DNA. The overall HPV detection rate in condylomata and intraepithelial or invasive neoplasia varied for the different genital areas: cervix (64%), vagina (56%), vestibule (59%), vulva (50%), and penis (42%). HPVs 6/11 were associated with condylomata, whereas HPV 16 was associated with intraepithelial and invasive neoplasia. Not a single case of intraepithelial or invasive neoplasia contained HPV 6/11, which supports the notion of the oncogenic potential of HPV 16. Condylomata were positive for HPV 16 only when adjacent to HPV 16-positive cervical intraepithelial neoplasias (CINs). The amount of viral DNA (copy number) was low in invasive cancers, intermediate in intraepithelial neoplasia, and conspicuously high in condylomata. In biopsies (n = 142) taken from lesions suggestive of subclinical papillomavirus infection on the basis of minor colposcopic and histologic abnormalities, HPV DNA was not detectable. Histologically normal tissue (n = 210) adjacent to condyloma, CIN, or cancer, and thus potential carrier of latent HPV infection, also proved negative for HPV DNA by in situ hybridization. The inability to detect viral DNA by in situ hybridization in tissues diagnosed as subclinically or latently infected may have been due to limited sensitivity of the hybridization method applied in this study.

Bone density in eumenorrheic female college athletes

Information is limited on the effect of exercise on bone density in young eumenorrheic athletes. We studied 12 Caucasian intercollegiate volleyball players (V), nine basketball players (B), ten swimmers (S), and 13 non-athletes (N) with bone density measurements by photon absorptiometry of their calcaneus and lumbar spine (L2-L4). The effect of athletic status on bone density was analyzed by multivariate analysis of covariance, with height and weight as covariates. The bone densities reported below are mean +/- SE, adjusted for the covariates; units = g.cm-2, P less than 0.005. The swimmers had a significantly lower mean density in the lumbar spine than all other groups; the non-athletes' mean density was also lower than that of volleyball players (V = 1.31 +/- 0.03, B = 1.26 +/- 0.04, N = 1.18 +/- 0.03, S = 1.05 +/- 0.03). The volleyball and basketball players' mean calcaneal densities were greater than those of the swimmers and non-athletes (V = 0.530 +/- 0.017, B = 0.564 +/- 0.023, N = 0.438 +/- 0.018, S = 0.375 +/- 0.019). The higher bone densities for athletes in vertical weight-bearing activities are consistent with some but not all published data. The swimmers' low bone density in the lumbar spine, less than published values for amenorrheic runners, was unexpected.

Sister Mary Joseph's nodule. Diagnosis of umbilical metastases by fine needle aspiration

Three cases of Sister Mary Joseph's nodule (umbilical metastases) are presented. The probable primary tumor in all three cases was an ovarian adenocarcinoma. Fine needle aspiration (FNA) was used to confirm the secondary nature of the umbilical lesion in one case. The entity is named after Sister Mary Joseph, who was Superintendent at the Mayo Clinic in the early part of this century. The primary lesion is most commonly found in the genital or gastrointestinal tracts. Since the prognosis for this lesion is extremely poor, with a mean survival of a few months, surgery is usually not indicated; FNA is recommended as a convenient means of confirming the suspected diagnosis.