[Javier Sádaba: A bioethics against suffering]

The philosopher Javier Sádaba (Portugalete, 1940) is the author of an extensive work in the field of bioethics. It is a procedural bioethics (based on the agreement between the participants, not on absolute truths), casuistry (is based on the analysis of specific problem cases), social (evaluates the context in decision-making), gradual (considers other species, is not "narcissistically human"), and secular (autonomous with respect to religion). Sádaba has also opted for an affirmative bioethics, which seeks to improve the living conditions of humans (in medicine, the quality of life). This is difficult to construct because, for the philosopher, the duty and to establish limits are infinitely easier to elaborate than the specific good and to pursue happiness. In its application to medicine, Sádaba's bioethics focuses on avoiding unnecessary suffering, because suffering does not contribute anything positive and hinders happiness. Likewise, he strives to extract the best of science and open the doors to everything that can bring improvements for the human being, but without ceasing to mention responsibility, because man is capable of the best and the worst. From this perspective, the author is faced with the bioethical issues, leaving the greatest possible margin to freedom of choice.

[Toxic epidermal necrolysis induced by phenytoin and whole brain radiotherapy]

Toxic epidermal necrolysis (TEN) and Stevens-Johnson syndrome (SJS) have been associated with some drugs, particularly anticonvulsants such as phenytoin. Some authors have pointed out an increased risk of TEN/SJS when phenytoin is associated with whole brain radiotherapy. We report a patient diagnosed with breast adenocarcinoma and brain metastases that was on treatment with phenytoin and, shortly after receiving whole brain radiotherapy, developed toxic epidermal necrolysis.

Lipid metabolism and occurrence of post-percutaneous transluminal coronary angioplasty restenosis: role of cholesteryl ester transfer protein and paraoxonase/arylesterase

Plasma lipid metabolic and transfer processes have recently been suggested to play an important role in the development of early restenosis, a major complication of percutaneous transluminal coronary angioplasty (PTCA); in particular, the common variants of genes for cholesteryl ester transfer protein (CETP) and paraoxonase (PONA) have been implicated. We had the opportunity to investigate this question in a large, prospective cohort characterized by quantitative coronary angiography in all subjects. The CETP-TaqIB (intron 1), CETP-MspI (intron 8), and PONA-AlwI (exon 2) polymorphisms were characterized in a cohort of 779 patients of whom 342 ("cases") had developed restenosis (as defined by > 50% loss of lumen compared with immediate postprocedure results) at repeat angiography at 6 months post PTCA. Selected frequencies for CETP B1 and B2 alleles (absence/presence of TaqIB site) were 0.65 and 0.35 (cases) and 0.65 and 0.35 (controls), respectively; frequencies for CETP M1 and M2 alleles (absence/presence of MspI site) were 0.20 and 0.80 (cases), 0.21 and 0.79 (controls), respectively; frequencies for PONA A and B alleles (absence/presence of AlwI site) were 0.73 and 0.27 (cases), 0.72 and 0.28 (controls), respectively. All observed genotype frequencies were in Hardy-Weinberg equilibrium. There was no evidence for gene-gene interaction, or an association between genotype and restenosis or degree of lumen loss (adjusted for covariates). Our data, collected in the largest study of its kind so far, indicate that the common variants for CETP and PONA are not associated with incidence of restenosis after PTCA, and are therefore not useful markers for risk assessment.

Multi-locus interactions predict risk for post-PTCA restenosis: an approach to the genetic analysis of common complex disease

The complexity of recognizing the potential contribution of a number of possible predictors of complex disorders is increasingly challenging with the application of large-scale single nucleotide polymorphism (SNP) typing. In the search for putative genetic factors predisposing to coronary artery restenosis following balloon angioplasty, we determined genotypes for 94 SNPs representing 62 candidate genes, in a prospectively assembled cohort of 342 cases and 437 controls. Using a customized coupled-logistic regression procedure accounting for both additive and interactive effects, we identified seven SNPs in seven genes that, together, showed a statistically significant association with restenosis incidence (P <0.0001), accounting for 11.6% of overall variance observed. Among them are candidate genes for cardiovascular pathophysiology (apolipoprotein-species and NOS), inflammatory response (TNF receptor and CD14), and cell-cycle control (p53 and p53-associated protein). Our results emphasize the need to account for complex multi-gene influences and interactions when assessing the molecular pathology of multifactorial medical entities.

Mesenteric tuberculosis with jejunal infiltration

A 69-year-old female was admitted to our hospital because of asthenia, anorexia and 20 kg weight loss. An ultrasound study and computerized tomography (CT) imaging revealed a mesenteric mass and laparotomy was performed. The diagnosis was mesenteric tuberculosis with jejunal involvement. This represents an atypical onset of tuberculosis in a non-immunosuppressed patient.

Ace D/I polymorphism and incidence of post-PTCA restenosis: a prospective, angiography-based evaluation

Early restenosis is the major complication of percutaneous transluminal coronary angioplasty (PTCA), occurring in approximately 30% of all initially successful procedures. The D/I polymorphism of the ACE gene, which has variably been reported to represent a risk factor for manifestations of ischemic heart disease, has recently been implicated in the pathophysiology of restenosis after PTCA by some investigators but not by others. All studies conducted thus far involved relatively small sample sizes. We investigated the possible association of ACE D/I genotype and post-PTCA restenosis in a large, prospective sample of patients followed by quantitative coronary angiography. The ACE D/I gene polymorphism was characterized in a cohort of 779 patients, of whom 342 (cases) had developed restenosis (as defined by >50% loss of lumen compared with immediate postprocedure results) at repeat quantitative coronary angiography at 6 months after PTCA. Allele frequencies for the ACE D and I: alleles were 0.58 and 0.42 in cases and 0.58 and 0.42 in control subjects. All observed genotype frequencies were in Hardy-Weinberg equilibrium. There was no evidence for an association between genotype and restenosis or degree of lumen loss. The data from this largest study of its kind conducted so far provide no evidence for an association of the ACE D/I allelic polymorphism with incidence of restenosis after PTCA. On the basis of the power of this study, we conclude that in a general population, the ACE D/I polymorphism is not a useful marker to assess risk of post-PTCA restenosis.

[Leukocytoclastic vasculitis associated with ticlopidine]

In the last five years the combination of ticlopidine plus aspirin has been the treatment of choice to avoid thrombi formation after the implantation of intracoronary stents. The adverse effects observed include the appearance of a maculopapulous, pruritic, painless, cutaneous rash. We present the case of a patient who developed leucocytoclastic vasculitis associated with the administration of ticlopidine.

Circulating monocytes in patients with diabetes mellitus, arterial disease, and increased CD14 expression

Low serum concentrations of high-density lipoprotein (HDL) cholesterol and elevated levels of acute-phase reactans are frequently found in patients with non-insulin-dependent diabetes mellitus (NIDDM) and cardiovascular disease. Changes in the phenotype of circulating monocytes have been reported with both of these circumstances in nondiabetic subjects. In the present study, we explored the possibility that similar changes may occur in circulating monocytes of patients with NIDDM and arterial disease. Two groups of subjects with NIDDM were studied: patients with cardiovascular disease (n = 25) were compared with a group without cardiovascular disease (n = 26); both groups were age- and sex-matched, had the same length of diabetes duration, and degree of glycemic control. Healthy nondiabetic volunteers of comparable age and sex (n = 35) formed the control group. There was no significant difference in the numbers of the CD14+/CD16+ monocyte subpopulations between the 3 groups. However, a significant graded increase of the mCD14 intensity expression values was observed among the groups, with the highest levels in patients with NIDDM patients and the lowest in nondiabetic subjects. The serum C-reactive protein concentrations were significantly higher in the group with arterial disease compared with those without arterial disease or healthy controls. In the group of patients as a whole, relative mCD14 intensity expression was significantly correlated with HDL cholesterol levels (inversely) and with serum concentrations of C-reactive protein. Serum HDL cholesterol levels and the C-reactive protein concentrations were also significantly correlated. We concluded that the increased mCD14 intensity expression on circulating monocytes may be an important contributor to the increased inflammatory response observed in patients with NIDDM and arterial disease, and eventually, to atherogenesis.

Pulmonary tuberculosis presenting with cutaneous leukocytoclastic vasculitis

This case report deals with a rare association: tuberculosis and cutaneous leukocytoclastic vasculitis. The patient was a 36-year-old man with no significant past medical problems. He presented with a palpable purpura on both legs, low-grade fever, cough and expectoration, progressive dyspnea due to a massive left pleural effusion and a symmetric swelling on his ankles and wrists. Skin biopsy yielded a histological diagnosis of leukocytoclastic vasculitis and the primary diagnosis was only achieved after performing a pleural biopsy, which unequivocally showed the presence of Mycobacterium tuberculosis. This case shares many features with the few cases already reported in the medical literature. Possible pathogenic mechanisms are reviewed and discussed in detail.

[Invasive aspergillosis in patients with human immunodeficiency virus infection diagnosed by necropsy: the contribution of 4 cases and review of the literature]

BACKGROUND

Invasive aspergillosis is an infrequent clinicopathological entity which is difficult to diagnose (since it requires tissue samples, normally of the lung where the pathogenic effect of the fungi may be seen) and thus an important number of cases are not found until necropsy. In patients with human immunodeficiency virus (HIV) infection the real incidence has not been clearly defined and may be higher than reported.

MATERIAL AND METHODS

We herein present a series of necropsy reviews performed over a five year period (January 1993 to December 1997) in the Hospital Universitario San Carlos in Madrid (Spain) in patients with HIV infection. In the patients who presented invasive aspergillosis a collection protocol of clinical, analytical and radiologic data was undertaken.

RESULTS

Over this period necropsic studies were performed in 23 patients with HIV infection. Of these 4 (17.3%) presented invasive aspergillosis; 3 with disseminated involvement. Premortem diagnosis was not performed in any of the cases. The risk factors included: 3 had a CD4 count of less than 50, two were receiving glucocorticoids and only 1 had severe neutropenia. In 2 another opportunistic lung infection was also observed.

CONCLUSIONS

Invasive aspergillosis is an entity witch is found on autopsy with relative frequency in patients with HIV infection with severe immunodepresion. Other opportunistic infections may also coincide and it may not be associated with neutropenia, glucocorticoid treatment, which are considered as classical risk factors for invasive aspergillosis.

[Diarrhea associated with Clostridium difficile. One-year retrospective study at a tertiary hospital]

BACKGROUND

Diarrhea associated with Clostridium difficile is a health care problem of growing importance in the last few years specially in the hospital environment. The epidemiologic data and factors associated with this disease have not, to date, been sufficiently studied in Spain.

METHODS

The cases of diarrhea associated with C. difficile reported in 1996 in a tertiary hospital of 1,500 beds were retrospectively reviewed, collecting clinical and epidemiologic data. The technique used for the detection of the C. difficile toxin was EIA Premier.

RESULTS

One hundred thirty-two patients were included in the study, 83.3% of whom were over the age of 65 years, who had had 148 episodes of diarrhea associated with C. difficile. Most had been admitted into internal medicine (36%) or in the geriatric department (25%) and the remaining in the surgical departments (16.4%) or others (22.6%). The most frequently prescribed antibiotics were third generation cephalosporins (28.6%), clindamycin (17%), quinolones (11.1%) and macrolides (9.1%). Most of the patients received from 2 to 4 antibiotics prior to presenting diarrhea. Thirteen percent of the episodes of diarrhea associated with C. difficile were exclusively treated with withdrawal of the prescribed antibiotic, while the remaining cases were also given specific treatment which in 68.6% of the cases was with metronidazole and 31.4% with vancomycin. No significant difference was observed in the evolution of the patients according to the antibiotic prescribed.

CONCLUSIONS

Diarrhea associated with C. difficile should be taken into account as a frequent complication of wide spectrum antibiotic treatment, specially in the elderly, immunosuppressed or in patients with pluripathology. With this study the authors wish to underline the need for the judicious use of antibiotics in the hospital environment and aid in the rapid diagnosis of this entity.

[Staphylococcus aureus bacteremia and a mass in the right atrium in a patient carrying a central port]

A male heroin abuser was admitted because of Candida endophthalmitis. A permanent central venous line was inserted. Three months later, he had positive catheter and blood cultures with Staphylococcus aureus. Transthoracic and transesophageal echocardiography and magnetic resonance revealed a right atrial mass. Treatment with antibiotics in addition to clinical and echocardiographic follow up was decided upon. Six weeks later, a transesophageal echocardiography showed a decrease in right atrial mass size and the patient was discharged asymptomatic without treatment. Three months later, he was well and a new transesophageal echocardiography showed a further decrease in atrial mass size with signs of fibrosis. This follow up supports the clinical suspicion of thrombus in the right atrium attributable to a central venous line and Staphylococcus aureus bacteremia.

[Ischemia of the lower limbs as the initial manifestation of Candida albicans endocarditis in a parenteral drug addict]

BACKGROUND

Multiple infective complications have been described in injection drug users (IDUs). Infective endocarditis, most frequently caused by Gram positive bacteria, with classical features, is one of the most dangerous. In a few patients fungi are the cause (less than 5%), and these develop an unusual clinical picture.

METHODS

An IDUs patient was admitted in our Hospital for subacute arterial ischemia at the inferior limbs. A mass inside the abdominal aorta was detected by echography and arteriography, which was removed surgically a few hours later.

RESULTS

The pathologic evaluation of the surgical specimen revealed its fungal composition; the culture of this material was characteristic of Candida albicans. The clinical suspicion of aortic endocarditis, as the emboligenic source responsible of the inferior limbs ischemia, was confirmed with the performance of an echocardiography. A few hours after surgery the patient got worse; 24 hours later he died due to uncontrolled bleeding of the surgical suture in the aorta.

CONCLUSIONS

Fungal endocarditis should be thought in IDUs patients presenting inferior limbs ischemia. Due to the high mortality of this disease, as soon as the diagnosis is suspected, urgent medical and surgical therapy should be started.

[Colonic tuberculosis as a cause of rectal bleeding in 2 patients with HIV infection]

BACKGROUND

Extrapulmonary tuberculosis is a relatively frequent disease in patients with HIV infection. This may be observed coinciding with pulmonary involvement or without diagnostic data of the same. Within extrapulmonary involvement, gastrointestinal involvement is one of the least frequently observed and its diagnosis is very difficult due to the scarce clinical suspicion because of the unspecific symptomatology.

METHODS

Segmentary colonic tuberculosis was diagnosed in two patients presenting rectal bleeding. The diagnosis was neither clinically nor endoscopically suspected and only histologic and microbiologic study of the biopsies led to establishment of the diagnosis. Pulmonary involvement was also seen in one of the 2 patients.

RESULTS

Medical treatment was initiated following the diagnosis. The evolution was good in one patient, while the other developed a picture of massive rectal bleeding requiring surgical resection following which the patient died due to complications.

CONCLUSIONS

Colonic tuberculosis is an infrequent disease in patients with HIV infection. Only a high index of clinical suspicion along with adequate histopathologic and microbiologic study of all the colonic lesion biopsies can establish the real frequency of this disease in this group of patients.