Unusual Case of Anuria Due to African Bee Stings

We describe a case of multiple African bee stings in which the exceptionally high dose suggests a direct effect of hymenoptera venom on the renal tubules. The case does not follow the previously reported pattern of hypovolemic or anaphylactic shock, hemolysis and/or rhabdomyolysis, despite the potentially lethal amount of venom injected

GH replacement therapy and second neoplasms in adult survivors of childhood cancer: a retrospective study from a single institution

PURPOSE

Growth hormone deficiency (GHD) is the most common endocrine late effect observed in childhood cancer survivors (CCS) previously submitted to cranial irradiation. Radiation therapy can also increase the risk of second neoplasms (SNs). Since in previous studies GH replacement therapy was associated with increased incidence of neoplasia, we explored the association between SNs and GH replacement therapy in a cohort of CCS with GHD.

METHODS

Within the clinical cohort of CCS referred to the Transition Unit for Childhood Cancer Survivors of Turin between November 2001 and December 2012, we considered all patients who developed GHD as a consequence of cancer therapies. GHD was always diagnosed in childhood. To evaluate the quality of data, our cohort was linked to the Childhood Cancer Registry of Piedmont.

RESULTS

GHD was diagnosed in 49 out of 310 CCS included in our clinical cohort. At least one SN was diagnosed in 14 patients, meningioma and basal cell carcinoma being the most common SNs. The cumulative incidence of SNs was similar in GH-treated and -untreated patients (8 SNs out of 26 GH-treated and 6 out of 23 GH-untreated patients; p = 0.331). Age, sex and paediatric cancer type had no impact on SNs development.

CONCLUSIONS

In our CCS, GH replacement therapy does not seem to increase the risk of SNs. Anyway, independently from replacement therapy, in these patients we observed an elevated risk of SNs, possibly related to previous radiation therapy, which suggests the need of a close long-term follow-up.

Karyotype-phenotype correlation in partial trisomies of the short arm of chromosome 6: a family case report and review of the literature

The first child (proband) of nonconsanguineous Caucasian parents underwent genetic investigation because she was affected with congenital choanal atresia, heart defects and kidney hyposplasia with mild transient renal insufficiency. The direct DNA sequencing after PCR of the CHD7 gene, which is thought to be responsible for approximately 60-70% of the cases of CHARGE syndrome/association, found no mutations. The cytogenetic analysis (standard GTG banding karyotype) revealed the presence of extrachromosomal material on 10q. The chromosome analysis was completed with array CGH (30 kb resolution), MLPA and FISH, which allowed the identification of three 6p regions (6p.25.3p23 × 3): 2 of these regions are normally located on chromosome 6, and the third region is translocated to the long arm of chromosome 10. The same chromosomal rearrangement was subsequently found in the father, who was affected with congenital ptosis and progressive hearing loss, and in the proband's sister, the second child, who presented at birth with choanal atresia and congenital heart defects. The mutated karyotypes, which were directly inherited, are thought to be responsible for a variable phenotype, including craniofacial dysmorphisms, choanal atresia, congenital ptosis, sensorineural hearing loss, heart defects, developmental delay, and renal dysfunction. Nevertheless, to achieve a complete audiological assessment of the father, he underwent further investigation that revealed an increased level of the coagulation factor XIII (300% increased activity), fluctuating levels of fibrin D-dimer degradation products (from 296 to 1,587 ng/ml) and a homoplasmic mitochondrial DNA mutation: T961G in the MTRNR1 (12S rRNA) gene. He was made a candidate for cochlear implantation. Preoperative high-resolution computed tomography and magnetic resonance imaging of the temporal bone revealed the presence of an Arnold-Chiari malformation type I. To the best of our knowledge, this study is the second report on partial 6p trisomy that involves the 10q terminal region. Furthermore, we report the first case of documented Arnold-Chiari malformation type I and increased factor XIII activity associated with 6p trisomy. We present a comprehensive report of the familial cases and an exhaustive literature review.

Endocrine health conditions in adult survivors of childhood cancer: the need for specialized adult-focused follow-up clinics

BACKGROUND

Survival rates among childhood cancer survivors (CCS) have enormously increased in the last 40 years. However, this improvement has been achieved at the expense of serious late effects that frequently involve the endocrine system.

AIM

To evaluate the cumulative incidence of endocrine diseases in a cohort of long-term CCS.

MATERIALS AND METHODS

We analyzed the clinical data of 310 adults, followed for a median time of 16.0 years after the first cancer diagnosis. The monitoring protocols applied to each patient were personalized on the basis of cancer diagnosis and previous treatments, according to the Children's Oncology Group guidelines.

RESULTS

The cumulative incidence of endocrine late effects steadily increased over time. At the last follow-up visit available, 48.46% of females and 62.78% of males were affected by at least one endocrine disease. The most common disorders were gonadal dysfunction, primary hypothyroidism, and GH deficiency (GHD). The main risk factors for endocrine disease were male sex (hazard ratio (HR)=1.45, 95% confidence interval (95% CI) 1.05-1.99), radiotherapy (HR=1.91, 95% CI 1.28-2.84), hematopoietic stem cells transplantation (HR=3.11, 95% CI 2.23-4.34), and older age at cancer diagnosis (HR=1.89, 95% CI 1.25-2.85). Male sex was associated with a higher risk of gonadal disorders, whereas radiotherapy specifically increased the risk of GHD and thyroid dysfunction.

CONCLUSIONS

Endocrine disorders among CCS have a high prevalence and increase over time. Thus, endocrinologists need to cope with an increasing demand for health care in a field that is still little developed and that, in perspective, could also be extended to some selected types of adult cancer survivors.

CEA versus CAS: short-term and mid-term results

AIM

Ischemic stroke represents a major health problem and it is an important cause of long-term disability. The aim of this study was to compare short-term and mid-term results of carotid endarterectomy and stenting.

METHODS

During a three-year period, we enrolled 300 patients with carotid stenosis that fit with Stroke Prevention and Educational Awareness Diffusion (SPREAD) guidelines and we performed 150 carotid endarterectomy operations (CEA) and 150 carotid artery stenting procedures (CAS) with distal protection devices. All patients underwent preoperative and postoperative: neurological examination, ultrasound imaging, magnetic resonance imaging (MRI) and cognitive tests; moreover all patients were submitted to preoperative, intraoperative and postoperative Transcranial Doppler (TCD) monitoring, in order to detect microembolic signals (MES).

RESULTS

Mortality was zero; two patients developed myocardial infarction in the CEA group during follow-up. The main post-operative results after endarterectomy versus CAS were respectively: neurological deficit: 1.3% vs. 3.3%, embolic lesions at postoperative MRI: 4% vs. 34% and worsening of cognitive tests: 4% vs. 25.3%.

CONCLUSION

CEA seems to be the treatment of choice for carotid stenosis, due to its low rate of mortality and morbidity, especially in asymptomatic patients; CAS should be carried out only in particular subgroup of cases, such as: restenosis, previous neck surgery or radian therapy, anatomical high bifurcation or extended lesions. Ongoing multicenter randomized trials may give a definitive answer to this matter.

C-peptide and the risk for incident complications and mortality in type 2 diabetic patients: a retrospective cohort study after a 14-year follow-up

OBJECTIVE

C-peptide, a cleavage product of insulin, exerts biological effects in patients with type 1 diabetes mellitus, but its role in type 2 diabetes mellitus is controversial. Our aim was to examine the associations between fasting C-peptide levels and all-cause mortality, specific-cause mortality and the incidence of chronic complications in patients with type 2 diabetes.

DESIGN

Retrospective cohort study with a median follow-up of 14 years.

METHODS

A representative cohort of 2113 patients with type 2 diabetes mellitus and a subgroup of 931 individuals from this cohort without chronic complications at baseline from a diabetic clinic were studied.

RESULTS

Patients with higher C-peptide levels had higher baseline BMI and triglyceride and lower HDL-cholesterol values. During the follow-up, 46.1% of the patients died. In a Cox proportional hazard model, after multiple adjustments, no significant association was found between the C-peptide tertiles and all-cause mortality or mortality due to cancer, diabetes or cardiovascular diseases. In the subgroup of 931 patients without chronic complications at baseline, the incidence of microvascular complications decreased from the first to the third C-peptide level tertile, while the incidence of cardiovascular disease did not differ. The risks for incident retinopathy (hazard ratio (HR)=0.33; 95% confidence interval (CI) 0.23-0.47), nephropathy (HR=0.27; 95% CI 0.18-0.38) and neuropathy (HR=0.39; 95% CI 0.25-0.61) were negatively associated with the highest C-peptide tertile, after adjusting for multiple confounders.

CONCLUSIONS

Higher baseline C-peptide levels were associated with a reduced risk of incident microvascular complications but imparted no survival benefit to patients with type 2 diabetes mellitus.

Frequency and severity of headache is worsened by Interferon-β therapy in patients with multiple sclerosis

BACKGROUND

The relationship between multiple sclerosis (MS) and headache (HA) is not well known. It was reported that interferon-beta (IFNβ) could induce or worsen HA.

OBJECTIVE

To evaluate the impact of IFNβ treatment on HA and the relationship between HA and the various commercial preparations of IFNβ in mildly disabled patients with MS.

METHODS

A specific questionnaire was administered to 357 relapsing-remitting MS patients. Characteristics of HAs were considered, including the temporal relationships with IFNβ administration.

RESULTS

One hundred and seventeen patients were treated with weekly intramuscular injections of interferon IFNβ-1a (Avonex(®)), 84 with subcutaneous injections of IFNβ-1b (Betaferon(®)) every other day, 48 and 108 with three times weekly subcutaneous injections of IFNβ-1a (Rebif(®)) 22 mcg or IFNβ-1a (Rebif(®)) 44 mcg, respectively. Three hundred and fourteen patients were affected by HA, and among them, 219 patients suffered of pre-existing HA. In this latter group, 121 subjects (55%) noted a worsening of their HA after starting IFNβ therapy; this was more frequently reported by patients treated with Avonex(®) and Rebif(®) 44. Ninety-five patients experienced new HA.

CONCLUSION

IFNβ treatment could worsen HA in patients with pre-existing HA or cause the appearance of new HA. Among different IFNβ preparations, Rebif(®) 44 and Avonex(®) seemed to be more cephalalgic than the other drugs.

Tibioperoneal true aneurysm: case report and literature review

BACKGROUND

The true aneurysms of the infrapopliteal arteries are an unusual pathology with low incidence in the general population. They appear in the literature only as isolated case reports. True aneurysms of the infrapopliteal arteries represent a surgical problem, especially when a bifurcation is involved and when the distal vessels are affected by occlusive disease.

CASE REPORT

A 67 year old man with an aneurysm which involved the tibioperoneal trunk and the origin of peroneal and posterior tibial arteries was surgical treated. At three months follow up, a duplex ultrasonography (DUS) control showed the bypass patency and the total exclusion of the aneurismal sac.

DISCUSSION

Although the aneurysms of the infrapopliteal arteries are very uncommon and often asymptomatic, their associated vascular lesions and/or ischemic complications can lead to high risk of limb loss. When the aneurysm is large and/or symptomatic, the surgical treatment becomes mandatory. A conservative treatment and DUS follow up could be reserved to elderly patients and when the aneurysm is small and asymptomatic.

Cavernous hemangioma of the external ear: case report and literature review

OBJECTIVES

To describethe occurrence of a cavernous hemangioma of the external auditory meatus extending to the middle ear and the retroauricolar region in an adult patient, and to review the relevant literature.

METHODS

Case report. We report the clinical presentation, imaging studies and surgical procedures used in the study.

RESULTS

The angiographic study showed that the blood supply of the mass originated from the posterior auricular artery. Via a retroauricular approach, this artery was isolated and ligated in order to control the intra-operative bleeding. A canal wall up mastoidectomy with posterior tympanotomy and a tympano-canaloplasty were performed, permitting a complete excision. At 36 months of follow-up, no clinical and radiological signs of recurrence were detected.

CONCLUSION

Surgical removal is the treatment of choice, with rare recurrence of the hemangiomas. Pre-operative evaluation is based on computed tomography (CT scan), but should be followed by magnetic resonance angiography (MR-angio) or intra-arterial digital subtraction angiography (IA-DSA), especially in case of wider lesions.

Sudden bilateral sensorineural hearing loss as an unusual consequence of accidental ingestion of potassium hydroxide

OBJECTIVE

To discuss the possible etiopathogenetic mechanism of inner ear damage induced by the ingestion of potassium hydroxide (KOH).

CLINICAL PRESENTATION AND INTERVENTION

We report the case of a 37-year-old patient with sudden bilateral sensorineural hearing loss after accidental ingestion of a KOH solution. The first ear, nose and throat examination disclosed only mild edema of the upper airways. He was treated in the intensive care unit and prescribed high-dose steroids, proton pump inhibitors and sucralfate for 2 weeks. Unfortunately, there was no recovery of the hearing loss, and no audiogram changes were noticed after 12 months of follow-up.

CONCLUSION

After exploring the possible etiopathogenetic mechanism involved, the authors believe that in this case, a transient severe hemodynamic imbalance can actually be considered to be the most reliable explanation for the inner ear damage and subsequent onset of permanent bilateral sensorineural hearing loss.

Accuracy of body mass index in detecting an elevated alanine aminotransferase level in adolescents

AIM

We evaluated the accuracy of body mass index (BMI) in detecting an elevated alanine aminotransferase (ALT) level in adolescents, taking into account the effects of gender, age, ethanol intake, hepatitis B virus (HBV) and hepatitis C virus (HCV) infections, and drug consumption.

SUBJECTS

A representative sample of 454 adolescents (11-17 years) from two cities in northern Italy was studied (the Dionysos Study).

METHODS

z-BMI was calculated as the z-score of BMI using national growth charts. Logistic regression was used to quantify the contribution of the variables of interest to an elevated ALT (> 30 UL(-1)). Odds ratios (OR) and 95% confidence intervals (95% CI) were calculated, and areas under receiver-operator characteristic curves (AUC) were used to evaluate accuracy.

RESULTS

An elevated ALT was detected in 21 adolescents (4.6%). Among the studied variables, only male gender (OR=6.7, 95% CI 2.0-23.2) and z-BMI (OR=2.1, 95% CI 1.4-3.2) were significant predictors of elevated ALT. The accuracy of the prediction was 0.69 (95% CI 0.59-0.79) for gender and 0.71 (95% CI 0.59-0.81) for z-BMI. By combining gender and z-BMI, the accuracy rose to 0.80 (95% CI 0.71-0.89).

CONCLUSION

BMI is a good predictor of elevated ALT in Italian adolescents and gender adds to the accuracy of the prediction.

Transcarotideal access for endovascular repair of descending thoracic aortic aneurysm with intentional coverage of celiac artery

Endovascular treatment of thoracic and thoraco-abdominal aortic aneurysm with celiac artery ostium coverage, seems to be safe according to the literature. We present a case in which the endograft deployement was achieved through a right common carotid artery access because four years before the patient was submitted to an axillo-bifemoral bypass with aortic graft removal and aortic stump ligature for infection. After endovascular repair the patient suffered from spinal cord ischemia, acute pancreatitis and spleen infarction. Probably, the new pancreatic event has been triggered by temporary visceral ischemia, acting on a pancreas damaged by a previous acute hemorrhagic pancreatitis.

Headache and Multiple Sclerosis: A Population-Based Case-Control Study in Catania, Sicily

We carried out a population-based case-control study to evaluate the association between multiple sclerosis (MS) and headache. We had previously determined the incidence of MS during 1990-1999 in Catania, Sicily, identifying 155 incident MS patients; these subjects underwent a telephone interview using a standardized questionnaire for headache. Diagnosis and classification of headaches were made according to International Headache Society criteria (1988). A control group was selected from the general population through random digit dialling. One hundred and one (65.2±) MS patients, of the 155 identified, and 101 controls were screened for headaches. Fifty-eight (57.4±) MS patients and 38 (37.2±) controls fulfilled the diagnostic criteria of headache. A significant association between MS and headache was found with an adjusted odds ratio, estimated by logistic regression, of 2.18 (95± confidence interval 1.27, 3.93). Frequency of headaches in our MS population is higher than in the general population, supporting the hypothesis of a possible association between these two conditions.

Osteoporotic vertebral compression fracture pain (back pain): our experience with balloon kyphoplasty

AIM

The aim of this study is to evaluate the safety and effectiveness of antalgic and functional results after interdisciplinary approach and treatment of vertebral compression fractures (VCF) with percutaneous balloon kyphoplasty (KP) by the pain medicine specialist.

METHODS

Between April and December 2004, after informed consent, 13 patients have been treated for a total amount of 15 KP. For L5 - T11 level spinal anesthesia was performed, above T11 local infiltration was used. The following parameters were recorded: intraoperative course, postoperative course, pain before and after treatment, vertebral height restoring and quality of life measuring on visual analogical scale (VAS) and quality of life questionnaire of the European Foundation for Osteoporosis (QUALEFFO) scale.

RESULTS

No complications or adverse events were recorded. VAS values for pain were 6.2+/-2.1 preKP vs 3.3+/-1.7 and 4.5+/-1.1 respectively postKP and at follow-up, with statistically significant differences. Vertebral heights were 53.5+/-16%, 71.2+/-21% and 68.1+/-13.5%, preKP, postKP and at follow-up respectively, with statistically significant differences, similarly to quality of life related parameters and QUALEFFO score.

CONCLUSION

Back pain due to vertebral compression fractures is a quite frequent diagnosis for the pain medicine specialist; KP is a new technique showing an association of a low incidence of complications with a success rate, both on pain control and on vertebral height restoring. In our study, KP proved to be a safe technique with a high success rate, both for pain relief and for vertebral height restoring, with immediate results and important consequences on the patient's quality of life, physical and mental status, with a low incidence of complications due also to the choice of performing this procedure in locoregional anesthesia.

Continuous intrathecal baclofen administration by a fully implantable electronic pump for severe spasticity treatment: our experience

AIM

With this 8-month study, we wanted to evaluate the efficacy of continuous intrathecal baclofen infusion delivery by a programmable pump for severe spasticity according to patient selection criteria, implantation technique and related parameters, and outcome after the initial follow-up period.

METHODS

Intrathecal baclofen infusion was initiated in 30 patients within 24 h after a test dose of the agent resulted positive in spinal anaesthesia. During the procedure and the follow-up period, the following parameters were measured: incidence of anaesthesiological or surgical complications and adverse events, postdural puncture headache, prolonged motor block, difficulty in wound healing, infection, necessity to remove the pump; clinical response as measured on the Ashworth and spasms scales, quality of sleep, autonomy, quality of life and pain before and after intrathecal baclofen therapy.

RESULTS

Perioperative vital parameters (mean duration of the operation, 86+/-13 min) were stable; no motor block or postdural puncture headache, early or late infection developed. The 1 case of delayed wound healing resolved with treatment; a dislocated catheter was repositioned in 1 other case. The differences in changes between pre- and posttreatment were statistically significant, with best results obtained on rigidity and pain. The mean length of hospital stay was 8+/-2 days. Baclofen tolerance was observed in 1 case, but resolved after baclofen holiday with morphine. One case of pump malfunctioning was resolved with replacement of the device; no new neurological deficits occurred thereafter.

CONCLUSIONS

The good clinical response to treatment of spasticity and rigidity, improved quality of life, pain reduction and patient satisfaction with short length of admission demonstrate the efficacy of intrathecal baclofen therapy. Safe and efficacious, this mode of treatment appears to be the gold standard for treating severe spasticity.

Primary repair in esophageal atresia. The results of long term follow-up

AIM

The aim of this study was to assess the impact of postoperative morbidity during a long-term follow-up (6-12 years) in children with esophageal atresia treated at birth by primary anastomosis.

METHODS

Fifteen children with esophageal atresia and tracheoesophageal fistula were surgically treated at birth and their follow-up was extended to at least 6 up to 12 years. Data included clinical examination, evaluation of nutritional habit, continuous video recording of barium esophagogram, esophageal manometry, 24-h esophageal pH-monitoring and esophageal endoscopy.

RESULTS

All the 15 patients completed the clinical evaluation and the set of tests. In the first 6 years, mild dysphagia and gastroesophageal reflux (GER) was observed in 3 cases whereas GER without dysphagia in 4 cases. These 7 patients were informed about simple nutritional behaviours to minimize symptoms and treated with H2-blockers. At long-term twelve-year analysis, all patients were between 50 degrees and 75 degrees percentile of expected growth. It was not referred peculiar food restrictions. Five patients showed mild dysphagia with solid foods; early satiety, epigastric burning and regurgitation were less frequent. Furthermore they showed multiple non-peristaltic body contractions at esophagogram and moderate impairment of esophageal motility at esophageal manometry. The 24-h esophageal pH-monitoring showed normal patterns in all patients. No major lesions of esophageal mucosa were detected at esophagoscopy.

CONCLUSIONS

Although GER and esophageal dysmotility are reported as frequent findings in patients who underwent primary repair for esophageal atresia, these disorders don't cause any relevant impairment to the quality of their nutritional habit.

Lack of IgA antineutrophil cytoplasmic antibodies in Henoch-Schönlein purpura and IgA nephropathy

To verify whether IgA antineutrophil cytoplasmic antibody (ANCA) represents a serologic marker in Henoch-Schönlein purpura (HPS), we examined sera from 41 patients with the disease. Control sera from 28 patients with primary IgA nephropathy (IgA-N), 26 IgG-ANCA-positive vasculitis, and 28 normal controls were also studied. An increased IgA binding to neutrophil cytoplasmic extracts but not to purified ANCA antigens was found in 12.2-14.6% of HSP patients and in 14.3-21.4% of IgA-N patients versus 3.5% of normal controls. IgA binding to neutrophil cytoplasmic extracts correlated with serum IgA levels, IgA-rheumatoid factor, and IgA-fibronectin binding capacity. Moreover, low amounts of IgG and fibronectin were detected as contaminants in neutrophil cytoplasmic extracts and fibronectin could partly inhibit the binding of IgA to "crude" extracts. We conclude that IgA-ANCA are neither diagnostically nor immunologically specific in HSP and IgA-N. Several factors present in the sera of patients with IgA-related nephropathies seem to contribute to the "false-positive" IgA-ANCA demonstrable in these patients.

Unusual case of anuria due to African bee stings

We describe a case of multiple African bee stings in which the exceptionally high dose suggests a direct effect of hymenoptera venom on the renal tubules. The case does not follow the previously reported pattern of hypovolemic or anaphylactic shock, hemolysis and/or rhabdomyolysis, despite the potentially lethal amount of venom injected.

Characterization of interstitial infiltrating cells in Berger's disease

The role of infiltrating blood-borne cells in the pathogenesis of renal damage in human glomerulonephritis is under active investigation. We have evaluated leukocyte infiltrates (number of cells/mm2) in the renal interstitium of 21 patients with Berger's disease and eight normal kidneys with monoclonal antibodies and a four-layer immunoperoxidase technique. In our population of patients, the number of infiltrating T-lymphocytes (OKT11+ cells) was significantly higher (median, 132) than in the normal kidneys (median, 60). This increase was mainly due to T-suppressor/cytotoxic lymphocytes (OKT8+ cells; median, 68), while T-helper/inducer lymphocytes (Leu 3A+ cells) and monocytes were in the normal range. T-lymphocyte infiltration was more marked in ten patients with impaired glomerular filtration rate (GFR) at the time of biopsy (median, 167) than in patients with normal GFR (median, 88). In addition, ten patients who showed deterioration of renal function during the subsequent follow-up, whatever their serum creatinine levels at the time of biopsy, had significantly more total T cells (median, 269), OKT8+ cells (median, 143), and Leu 3A+ cells (median, 105) than 11 patients with persistently stable GFR and normal controls. More data are necessary to establish whether this T-lymphocyte infiltration is the consequence of a cell-mediated mechanism acting in the interstitium, concomitant with the immune-complex-mediated mechanism acting in the glomerulus, or is a nonspecific consequence of the tubulointerstitial damage induced by the immunologically mediated glomerular disease.

Identification of glomerular immune deposits in cryoglobulinemia glomerulonephritis

To provide further evidence of the nature of intraglomerular immune deposits in essential mixed cryoglobulinemia (EMC), we used two mouse monoclonal antibodies against cross-reactive idiotypes present on monoclonal rheumatoid factors (MoRFs) from patients with type II-EMC. MoAb Cc1 reacted with 9 of 16 circulating IgMk MoRFs tested, and MOAb Lc1 with four of the remaining. Using indirect immunofluorescence and immunoperoxidase techniques, we could identify the same cross-reactive idiotype of the serum MoRF in the renal biopsy specimens from 11 of 13 patients with EMC glomerulonephritis. Kidney specimens from the three patients, whose MoRF was not recognized by MoAbs Cc1 and Lc1, were negative. Two out of 30 control renal biopsies from patients with other forms of glomerulonephritis were shown to contain idiotype (Cc1 and Lc1) positive material. Both patients had serum polyclonal RF which could account for this finding. In conclusion, our results provide direct evidence that serum cryo-MoRF participate in the formation of glomerular immune deposits and, presumably, in the pathogenesis of renal damage in EMC glomerulonephritis.

The relationship of infiltrating renal leucocytes to disease activity in lupus and cryoglobulinaemic glomerulonephritis

In order to evaluate the contribution of cellular immune mechanisms in the pathogenesis of immune complex-mediated glomerulonephritis, renal biopsies from 18 patients with lupus glomerulonephritis and 26 with cryoglobulinaemic glomerulonephritis were studied. Leucocyte profiles including T cell subsets and 'activated' macrophages within both glomeruli and interstitium were determined, using a panel of monoclonal antibodies as markers, and a sensitive 4-layer peroxidase technique to localize these within tissues. The infiltrating leucocytes were correlated with clinical, histological and immunological parameters of disease activity. Normal glomeruli contained few leucocytes though normal interstitium did (145 +/- 30 mm2), made up predominantly of T lymphocytes and macrophages. There was a significant increase in intraglomerular leucocytes in both systemic lupus erythematosus 4-fold, and essential mixed cryoglobulinaemia 7-fold, as compared to normal. These leucocytes consisted mainly of macrophages, and particularly in cryoglobulinaemia of 'activated' macrophages as demonstrated by their surface expression of the procoagulant tissue factor recognized by the A13 monoclonal antibody. In cryoglobulinaemic glomerulonephritis (GN) there was also a significant increase in T lymphocytes due to a predominance of suppressor-cytotoxic cells (OKT8+). There was a significant increase in interstitial leucocytes in both diseases, lymphocytes (mainly OKT8+ve), and macrophages (mainly 'activated' A13+ve). There were significant positive correlations between disease activity and interstitial leucocyte infiltration including, in lupus nephritis, degree of proteinuria and total leucocytes, hypocomplementaemia and T lymphocytes, increased numbers of monocytes and lymphocytes with a higher histological index of activity, and in cryoglobulinaemic GN of T lymphocytes and proliferative lesions, and T lymphocytes and C1q deposition. This study has demonstrated the importance of the interstitium in the pathogenesis of both diseases, delineated the presence of both T lymphocytes and activated monocytes which make cell-mediated immune mechanisms feasible, and linked the presence of immune mediators to disease activity.

The detection of monocytes in human glomerulonephritis

Renal biopsy specimens from 343 patients with primary or secondary glomerulonephritis (GN) were examined for monocytes by the non-specific esterase reaction. Large numbers of monocytes per glomerulus (M/G) were found in essential cryoglobulinemia GN (29 pts, M/G 30.6 +/- 22.4), in acute post-infectious GN (27 pts, M/G 9.1 +/- 8.3), in rapidly progressive crescentic GN (20 pts, M/G 5.6 +/- 2.7), in systemic lupus GN (61 pts, M/G 5.0 +/- 5.6), and in IgA-GN associated with chronic liver disease (5 pts, M/G 6.4 +/- 5.9) or Schönlein-Henoch purpura (15 pts, M/G 3.3 +/- 6.4). Clinico-histological correlation showed that monocyte infiltration was correlated with the extent of proteinuria (all groups), with the presence of endoluminal "thrombi" (cryoglobulinemia GN), of polymorphonuclear leukocyte infiltration (post-infectious GN), of cellular crescents (crescentic GN), of "active" lesions (lupus GN), and with the extension of lesions to the peripheral capillary walls (IgA-associated GN). The M/G index was negligible in renal amyloidosis (21 pts), in idiopathic membranoproliferative GN (10 pts), in idiopathic IgA mesangial GN (63 pts), in membranous GN (40 pts), in focal glomerulosclerosis (29 pts), in minimal change nephropathy (18 pts), and in diabetic glomerulosclerosis (5 pts). The results confirm the participation of cells of the monocyte-macrophage series in the genesis of proliferative lesions, both intracapillary and extracapillary, in immune-mediated human GN and suggest their direct involvement in glomerular injury.

Heterogeneity of carnitine-palmitoyltransferase deficiency

Episodes with muscle ache, rhabdomyolysis and myoglobinuria with or without associated renal insufficiency are characteristic of muscle carnitinepalmitoyltransferase (CPT) deficiency. However, patients differ from each other in many aspects, such as the kind of stimulus that triggers rhabdomyolysis, the ability to produce ketone bodies when fasting, whether the enzyme defect is localized in skeletal muscle or is general, and the nature of the enzyme defect, which may be in CPT I or CPT II or both. Studies of muscle, liver and fibroblasts from a patient with recurrent rhabdomyolysis spontaneously occurring or triggered by exercise or fever, revealed a CPT deficiency in the muscle and liver biopsy samples but normal CPT activity in cultured cells, differing from previously reported patients. The enzyme defect in muscle was evidenced by two different methods, but not when determined with a method that measures the formation of palmitoylcarnitine. The enzyme abnormality in the patient's liver was associated with a delayed ketone body production and with a dramatic increase in long-chain acylcarnitines in the serum when fasting. Moreover the patient was unable to build up ketones when fed long-chain triglycerides (LCT) but showed prompt ketogenic response when fed medium-chain triglycerides (MCT). The heterogeneity of clinical presentations and of the biochemical findings in patients with CPT deficiency are discussed.