Urticaria, nephritis, and pseudotumor cerebri

The spectrum of chronic urticarial disease ranges from chronic urticarial skin lesions alone to well-characterized systemic lupus erythematosus with urticarial vasculitis as the major skin manifestation. Within this spectrum is the syndrome of urticarial vasculitis associated with systemic disease manifestations. There have been six previously recorded cases of urticarial vasculitis associated with pseudotumor cerebri. At least two of these have included membranoproliferative glomerulonephritis. The authors report a case of chronic urticarial disease associated with pseudotumor cerebri and membranoproliferative glomerulonephritis, but without demonstrable vasculitis. It is possible that this represents a distinct entity within the spectrum of chronic urticarial disease and cca be easily screened for in clinical practice.

Assay of a urinary CF-lectin factor as a second diagnostic test for cystic fibrosis

Analysis of urine samples for a lectin-like factor in patients with a diagnosis of cystic fibrosis (CF) revealed that the low molecular weight (MW) factor is present in urine only from such patients and not from heterozygous carriers of the CF gene or from normal controls. The urine fraction containing the factor must be separated from whole urine by a gel filtration column (TSK-20) for the activity to appear. The assay requires addition of an aliquot of normal serum to provide the necessary IgM to which the CF-factor binds, resulting in the lectin-like activity that causes agglutination of mouse erythrocytes. All 22 CF patients tested, who were not receiving intravenous (IV) antibiotics had positive CF-lectin urinary activity, whereas five others receiving IV aminoglycosides were negative. Four patients with a clinical diagnosis of CF, but with normal sweat tests (35-54 mEq/L), all had positive urinary CF-lectin tests. A blind study in which urine samples were shipped from Miami, FL to Sepulveda, CA was completely successful in correctly identifying 11 samples from CF patients as compared with ten from non-CF patients. It was concluded that an assay for urinary CF-lectin factor is specific and reliable for confirming a diagnosis of CF when the sweat test is indeterminate, and when patients have not received recent IV aminoglycosides.

Age-related decrease in serum angiotensin converting enzyme activity: the role of thyroidal status and food intake

The serum ACE activity was determined in male Fischer 344 rats at 2, 6, 13, and 25 months of age to determine whether serum angiotensin converting enzyme (ACE) activity is a potential biomarker of tissue hypothyroidism in aged rats. Since rodent serum contains an ACE activity inhibitor, the measurements were done in both undiluted and 1:8 diluted sera. The highest serum inhibitor activity was found in the 2-month-old animals. The serum ACE activity measured in the diluted serum of the aged rats (77.6 +/- 2.9 units/ml) was significantly reduced compared to 2-month-old (178.2 +/- 6.4 units/ml), 6-month-old (101.5 +/- 6.1 units/ml) and 13-month-old rats (84.9 +/- 8.6 units/ml); (p less than 0.001). Hyperthyroidism induced by injecting L-triiodothyronine (T3) 15 micrograms/100 gm body weight intraperitoneally for 10 days increased the serum ACE activity in the older rats, but reduced the levels in 2-month-old rats. There was no significant change in 6-month-old rats. The levels of serum ACE activity in hypothyroid 6-month-old rats (95.5 +/- 3.5 units/ml) and in 2-month-old-rats (94.2 +/- 4.0 units/ml) were similar to the level seen in hypothyroid old rats (88.9 +/- 5.8 units/ml). Pair feeding of young rats (8 months old) with old did not alter the baseline ACE level (117.4 +/- 3.7 units/ml) or the T3 stimulated (105.2 +/- 10.2 units/ml) serum ACE activity. It is concluded that the reduced serum ACE activity in aged rats cannot be accounted for by the reduced caloric intake or reduced serum thyroid hormone levels.(ABSTRACT TRUNCATED AT 250 WORDS)

Enzymes in sarcoidosis. Angiotensin-converting-enzyme (ACE)

Measurement of serum angiotensin-converting-enzyme (SACE) is the most useful test for diagnosing and monitoring disease activity in sarcoidosis. Because elevated levels of SACE are not specific for sarcoidosis, other conditions in which SACE levels are also elevated are examined.

Effect of captopril and enalapril medication on the serum ACE test for sarcoidosis

The presence of an intrinsic inhibitor of ACE in blood of approximately 25% of sera submitted for serum ACE assay in the diagnosis and evaluation of patients with sarcoidosis, and the common use of ACE inhibitors (captopril and enalapril) in the treatment of hypertension and congestive heart failure, stimulated these studies to compare the effects of the intrinsic and medicinal inhibitors upon serum ACE activity. Since the intrinsic ACE inhibitor in man is affected by serum dilution (inhibition is reversed) and by dialysis (inhibition becomes irreversible), these manipulations were also studied with medicinal inhibitors to provide guidelines for suspecting their presence in submitted serum samples without an accompanying history. Enalapril was found to have delayed onset of action after oral administration (1-2 hours), and was even further delayed (4 hours) when the intrinsic inhibitor also happened to be present. Inhibition by enalapril was not attenuated with refrigerated storage, with dilution or with dialysis of the serum. Captopril had a more rapid time of onset of ACE inhibition, but its inhibitory activity was markedly reduced with refrigerated storage of the serum; patients showed either a short half-life for the effect (1-4 days) or a prolonged half-life (10-17 days). Inhibitory activity of captopril was reversed following dilution of serum or following dialysis. The reversal of inhibition by captopril following dialysis, therefore, differed from the effect of dialysis on the intrinsic ACE inhibitor.(ABSTRACT TRUNCATED AT 250 WORDS)

3,5,3'-triiodothyroacetic acid therapy for thyroid hormone resistance

3,5,3'-Triiodothyroacetic Acid (Triac) is reputed to suppress pituitary secretion of TSH with minimal metabolic effects. Triac has been used successfully to treat eight patients with thyroid hormone resistance. We gave Triac to a woman with selective pituitary resistance for treatment of hyperthyroidism (patient 1) and to a man with generalized resistance and chronic schizophrenia to determine whether it would improve his schizophrenia (patient 2). Patient 1 was given 0.35-3.5 mg Triac/day; patient 2 was given 0.7-4.2 mg/day. Dosages were increased by 0.7 mg/day every 2 weeks. Serum T3, T4, free T4, TSH, TSH response to TRH, systolic time intervals (STI), angiotensin-converting enzyme (ACE), and lipids were monitored bimonthly. In both patients, there was no change in symptoms, weight, lipids, or STI. In patient 1, basal TSH suppressed from 16.3 to 1.5 mU/L; in patient 2, from 2.0 to 0.5 mU/L. The peak TSH response to TRH stimulation decreased from 144 to 12.5 mU/L in patient 1 and from 14.2 to 2.8 mU/L in patient 2. Serum T4 decreased from 160 to 109 nmol/L in patient 1 and from 270 to 192 nmol/L in patient 2. ACE levels were persistently elevated in both patients. Resting energy expenditure, measured by oxygen consumption, was increased by Triac in both patients (12% in patient 1 and 9% in patient 2). Although Triac suppressed TSH and T4 secretion in both patients, it did not reduce peripheral action of thyroid hormone as expressed in STI, resting energy expenditure, and ACE. We conclude that in these two patients with resistance to thyroid hormone, at the doses used to suppress TSH and T4 secretion, the intrinsic peripheral action of Triac offset whatever decrease in thyroid hormone secretion it produced.

Clozapine pharmacology and tardive dyskinesia

Clozapine, an atypical neuroleptic, does not cause extrapyramidal symptoms of Parkinsonism and dystonia and appears to have a reduced or absent capacity to produce tardive dyskinesia. 37 subjects, most with chronic schizophrenia, were treated with clozapine and TD outcome was analyzed. A subset of these subjects underwent plasma and CSF studies. TD response was heterogenous, but a proportion of patients improved with clozapine treatment. Neurochemical data differed from published reports of classical neuroleptics with the most robust effect produced by clozapine seen in CSF norepinephrine levels. Other neurochemical data and implications for the mechanism of clozapine in TD are reviewed.

Effect of menses, estrogens and hemolysis on a serum-lectin-like factor in cystic fibrosis

Twelve CF heterozygous and two CF homozygous women who were tested serially for the CF-lectin activities during one to two months of their menstrual cycles, were found consistently to have negative tests during menses. The specific hormonal alteration during menses that affects the assay is unknown. However, estrogenic medication administered without progesterone to postmenopausal heterozygous women also caused false-negative tests, suggesting that a balance between progesterone and estrogen is critical for the CF-lectin activity; mere depletion of these hormones alone does not interfere. The addition of estrogen in vitro also inhibited the CF-lectin activity at a physiologic concentration of 10(-6) M, and addition of an equivalent concentration of progesterone blocked this inhibitory effect. Future studies of the CF-lectin or its assay as a potential CF-carrier test must be limited to those women not menstruating at the time of blood drawing and not receiving estrogens. Hemolysis or contamination of the serum with RBC should invalidate that sample for testing, although the effect of RBC contamination can be circumvented with the addition of mannose. A more objective, simplified means of performing the CF-lectin assay is reported. A preliminary blind study taking these issues into consideration was 100 percent correct in detecting 16 CF patients and 17 obligate heterozygotes, and revealed 4 percent of 64 control subjects to have positive tests. The presence of this lectin-like factor may reflect the underlying biochemical defect responsible for this disease.

Epidemiological aspects of tardive dyskinesia

Although there continues to be some debate as to the extent to which neuroleptic drug treatment is either necessary or sufficient to produce abnormal involuntary movements in various psychiatric populations, the consensus at present is that neuroleptics do play a major role in producing, precipitating or evoking abnormal involuntary movements. No doubt a variety of other factors play a critical role in predisposing particular individuals to the development of the condition. Numerous prevalence surveys have been conducted and extensively reviewed. In general, prevalence surveys have helped to identify populations at particular risk, to suggest factors which contribute to risk and to establish the overall scope of the problem. The strategy of estimating prevalence in a specific population has limitations, however, and further advances in our understanding of tardive dyskinesia (TD) will require a different type of methodology. Important progress has been made in the last several years involving prospective studies of TD development. Current estimates of incidence suggest that TD develops in about 5% of patients with each year of cumulative neuroleptic exposure. These data are derived from relatively young patients (average age 28); the incidence in older individuals is likely to be higher. Further data on the epidemiology of TD will be presented.

Pharmacologic characterization of tardive dyskinesia

Tardive dyskinesia (TD) occurs in approximately 20% of patients treated chronically with antipsychotic drugs and constitutes a major public health problem. The cause of this disorder remains unknown, and no effective treatment has yet been found. The major etiologic theory (dopamine [DA] supersensitivity hypothesis) suggests that TD is the pharmacologic opposite of Parkinson's disease and implies that all patients with TD should respond uniformly to specific pharmacologic agents. Clinical research, however, has not borne this out. To evaluate pharmacologic response in TD syndromes, 15 patients underwent single dose acute administration of four different drugs: a DA agonist (bromocriptine 5 mg orally), a DA antagonist (haloperidol 5 mg intravenously), a cholinergic agonist (physostigmine 2 mg intravenously) and a cholinergic antagonist (benztropine 4 mg intravenously), individually in separate procedures at weekly intervals for four consecutive weeks in randomized order and under controlled double-blind conditions. Patients were evaluated for their clinical and endocrine responses. Pre- and post-drug administration TD exams were blindly rated. Results were not consistent with the DA supersensitivity theory; instead they demonstrated marked inter- and intrasubject variability in pharmacologic responses. Greatest uniformity in response was found among the tardive dystonic subjects, although this also was not consistent with a DA supersensitivity hypothesis. TD appears to be a pharmacologically heterogeneous condition, which may reflect the neurochemical complexity of the basal ganglia.

Pharmacologic studies of tardive dyskinesia

Based on the results of two preliminary studies, we concluded that late-developing persistent drug-induced movement disorders are pharmacologically heterogeneous, and this heterogeneity is seen between individual patients (and groups of patients) as well as within body areas of individual patients; dystonic pathology has a distinct and more consistent response to pharmacologic stimulation than does nondystonic tardive dyskinesia (TD); and, although disturbances in dopamine and acetylcholine appear to be involved in these disorders, they do not in all cases exist in functionally opposite relationships. The observed pharmacologic heterogeneity in TD response reflects the limitations of the dopamine/acetylcholine model of TD, which oversimplifies the neuroanatomy of the basal ganglia and the pathophysiology of TD. The chemical and anatomical complexity of this region suggests that other neurotransmitter systems and neuronal circuits within and extending from the basal ganglia may be disturbed in the pathogenesis of TD.

Tardive dyskinesia: prevalence, incidence, and risk factors

Despite increased attention to the problem of tardive dyskinesia (TD), many questions remain unresolved. There is a consensus that neuroleptics play a substantial role in its development, but other variables must also contribute. Prevalence surveys have helped to define the scope of the problem and suggest risk factors for further study. Their usefulness has been limited by methodological problems including the difficulty of estimating false-negative (masked) dyskinesia and false-positive (movements caused by other neuromedical conditions) rates. A recent large scale survey reported an overall rate of abnormal involuntary movements of 23.4% among neuroleptic-treated psychiatric patients; the range was from 12.3% among outpatients at a Veterans Administration hospital to 37.4% among state hospital inpatients. Rates of covert dyskinesia, obtained by withdrawing medication from 70 TD negative cases, ranged from 17% for the Veterans Administration to 67% at the state hospital (overall rate, 34%). Very few clear false-positive cases were found. The incidence of TD, based on a large prospective study of young adult patients, is 19% after 4 years of cumulative neuroleptic exposure. Higher incidence rates have been found in prospective studies of older patient samples. Age remains the risk factor most consistently associated with TD development; it may also relate to increased persistence. Female sex among older populations, diagnosis of affective disorder, and evidence of neuroleptic-induced pseudoparkinsonism also relate to increased risk. Further work is needed to elucidate the role of dosage and length of neuroleptic treatment, as well as other potential contributory factors.

Lymphadenopathy in an inner-city population consisting principally of intravenous drug abusers with suspected acquired immunodeficiency syndrome

Generalized lymphadenopathy in intravenous drug abusers (IVDAs) at risk for AIDS has not been well studied. We have retrospectively analyzed the results of lymph node biopsies obtained from 27 patients referred to the Infectious Diseases Service for evaluation of generalized lymphadenopathy and suspected AIDS during a recent 18-month period. Fourteen of the patients were heterosexual IVDAs, 7 were male homosexual IVDAs, and 6 were male homosexual non-IVDAs. All of the patients were residents of the Bronx, New York. Mycobacterium tuberculosis (TB) was the most frequent diagnosis established on lymph node biopsies from IVDAs, in 12 out of 21 (57%). Tuberculous adenitis was not diagnosed in the 6 non-IVDAs. All TB patients were febrile, 11 (91%) had lost weight, and 10 (84%) had an abnormal chest roentgenogram. The 5TU PPD skin test, however, was reactive in only 2 (16%) of 12 patients. Tuberculosis is important to consider in patient populations with exposure histories to both AIDS and TB. The alarmingly high prevalence of TB in this drug addict population emphasizes the importance of lymph node biopsies with acid-fast smears and mycobacterial cultures in symptomatic IVDAs. Preventive antituberculosis therapy for HIV-positive persons, especially IVDAs, with a history of positive tuberculin reactions or of recent household contact should be seriously considered.

Age and denture experience as determinants in patient denture satisfaction

Sixty-nine male patients participated in a self-evaluation survey measuring their satisfaction with maxillary and mandibular dentures. Patients generally had a high evaluation of their dentures, with the highest scores given to appearance. Age was not a significant predictor of denture success. Patients receiving their first dentures consistently had more difficulties in all categories of function, comfort, and appearance than patients with past experience with dentures.

Necrotizing sialometaplasia

A case of necrotizing sialometaplasia in a 29-year-old man is reported. Characterized by large, deep, well-demarcated ulcerations on the hard palate and other areas where salivary gland tissue is found, the condition is benign and resolves spontaneously. The cause is believed to be infarctive.

Noma

We report a case of noma in a debilitated 71-year-old white man. Predisposing factors included malnutrition, preleukemic syndrome, and occult renal adenocarcinoma. The superior third of the patient's lower lip was destroyed before he died.