[Complicated course of rheumatoid arthritis with pulmonary involvement, myocardial fibrosis and sleep apnea syndrome]

We report on a 67 year old man in whom the chest x-ray revealed marked interstitial opacities in both lungs. The diagnosis of Rheumatoid Arthritis (RA) was established by the presence of five criteria of the American College of Rheumatology for diagnosing RA. High resolution computertomography of the chest confirmed the abnormalities seen in the conventional chest x-ray. A biopsy, taken by open lung surgery, showed the typical pattern of pulmonary involvement in RA and confirmed the association of RA and interstitial lung fibrosis. The histologic examination pointed out lymphocytic infiltration of the bronchies, thickened alveolar walls with lymphoplasmarcellular infiltration and an increase in fibrous connective tissue. A congestive heart failure with severe arrhythmias and an obstructive sleep apnea syndrome (OSAS) were diagnosed in addition. The rhythm disturbances were attributed to the participation of the myocardium in RA and/or by the OSAS. By the treatment with prednisolone, methotrexate, mexiletine and continuous positive airway pressure (CPAP) the rhythm disturbances were alleviated and the patient's condition improved.

Changed excretion of urinary proteins and enzymes by chronic exposure to lead

Fifteen various serum and urine parameters were evaluated as indicators of renal alterations induced by lead in 82 male workers of a battery plant chronically exposed to lead (median of blood lead concentration: 2.03 mumol/l). The control group comprised 44 non-exposed healthy volunteers (0.34 mumol/l). High-molecular-mass proteins (transferrin, immunoglobulin G (IgG), (albumin)) were determined in urine as markers of glomerular integrity; low-molecular-weight proteins and parenchymal enzymes (alpha 1-microglobulin, beta 2-microglobulin, retinol-binding protein, lysozyme, ribonuclease, N-acetyl-beta-D-glucosaminidase (NAG), alanine aminopeptidase (AAP), alkaline phosphatase (AP), gamma-glutamyltransferase (GGT)) as indicators of changes in the proximal tubule; Tamm-Horsfall glycoprotein and kallikrein as markers of the distal tubule. There was a positive correlation between tubular indicators and blood lead concentration as well as the erythrocyte protoporphyrin (EPP). About 30% of the lead-exposed workers showed an increased excretion of alpha 1-microglobulin, NAG, ribonuclease, and/or Tamm-Horsfall protein, whereas the glomerular indicators remained unchanged. The combined determination of NAG and alpha 1-microglobulin in urine could be helpful in the early detection of lead-induced changes in the nephron.

[Ocular toxocara canis in a 30-year-old adult]

Pars plana vitrectomy was performed in a 30-year-old patient who presented a posterior traction detachment due to an inflammatory granuloma. The granuloma removed in toto during surgery revealed characteristic features of toxocariasis lesion (first case described in the literature). An ELISA test performed on a vitreous sample was strongly positive. Retinotomy around the granuloma was necessary to re-attach the retina and silicone oil was used as a tamponade for 4 months. VA improved from HM to 15/200 after silicone removal.