P728 Left main coronary artery thrombus found in a teenager with Kawasaki disease following cardiac arrest

Background

A male teenager presented with an out of hospital cardiac arrest while exercising requiring CPR and DC Cardioversion. Incidentally, he was stung by a wasp minutes before the event.

After being admitted, the patient was intubated, ventilated and treated for anaphylaxis and seizures. The patient had no significant past medical or family history of note. Investigations were performed after the patient was stabilized including 15 lead ECG, 24 hours ECG monitor, Echocardiogram and blood sample for troponins and cardiomyopathy screening. The ECG and 24 Hours ECG were reported as normal. The patient also had an exercise treadmill test which showed ischaemic changes at peak exercise. Cardiomyopathy screening was negative.

Echocardiogram showed globally mildly impaired left ventricular systolic function with no other significant abnormalities.

The patient underwent a cardiac MRI a couple of weeks later which showed an aneurysmal and tortuous proximal left coronary artery with a thrombus and also an aneurysmal mid left circumflex artery. Anticoagulation therapy was initiated, and a Cardioverter Defibrillator was implanted.

Another echo was performed focused on the LV function and visualisation of the coronary arteries. This confirmed the cardiac MRI findings, demonstrating two coronary artery aneurysms and a filling defect suggestive of thrombus in the more distal of the two aneurysms.

Due to the lack of evidence of any other potential condition, a diagnosis of Kawasaki disease was made and anticoagulation therapy was continued.

Conclusion

Although Kawasaki disease (KD) has been investigated for over four decades, its cause is still unknown. Current understanding of the immune system response indicates response to a classic antigen, that in most patients is protective against future exposure (1).

KD is an acute, self-limited vasculitis that affects young children. In a significant proportion of patients, it can originate coronary artery abnormalities, predominantly if the diagnosis is not achieved or treatment gets delayed. In the course of acute illness, the vascular architecture is destroyed by a necrotizing arteritis, causing hydrostatic pressure and leading to aneurysms in the affected areas (2).

The imaging modality preferred for assessment of myocardial function and detection of coronary artery abnormalities is Echocardiography (2).

In this case, given the unusual presentation of cardiac arrest and the diagnosis of KD we recommend a thorough assessment of the coronary arteries in echocardiography routinely.

Abstract P728 Figure.

Glutathione peroxidase levels throughout normal pregnancy and in pre-eclampsia

OBJECTIVE

Evidence suggests that hemoglobin, in addition to its function as a carrier of oxygen, also serves to transport nitric oxide, as S-nitroso cysteine, from the lungs to the peripheral circulation, where it can be released. Glutathione peroxidase, besides being an important antioxidant, is known to catalyze the release of nitric oxide from smaller carrier molecules, and may play a role in the distribution of nitric oxide throughout the body. In light of these findings, we sought to determine whether glutathione peroxidase levels differed throughout gestation, and specifically between pre-eclamptic and normal women.

METHODS

A nested case-control study of women receiving routine prenatal care was conducted. Pre-eclampsia was defined by a blood pressure of at least 140 mmHg systolic and/or 90 mmHg diastolic as well as proteinuria > 300 mg/24 h or > 2+ by dipstick, both occurring on two occasions at least 6 h apart. Blood was collected in heparinized tubes and was then centrifuged in a clinical centrifuge for 10 min. Plasma was frozen promptly at -80 degrees C for later enzyme-linked immunosorbent assay (ELISA), with which plasma glutathione peroxidase was determined.

RESULTS

The maternal demographics of the pre-eclamptic and non-pre-eclamptic study groups did not significantly vary with respect to mean maternal age, gravidity, parity and gestational age at the time of delivery. The median maternal ages were 33 and 34 years, and the median gestational ages at the time of birth were 37.5 and 38.1 weeks, respectively. In evaluating the glutathione peroxidase levels of all patients across the three trimesters, we found that there was essentially no difference in mean levels (83.7, 81.0 and 89.5 ng/ml, respectively). There was no difference between the pre-eclamptic and non-pre-eclamptic patients, again stratified by trimester. A linear regression analysis indicated that the plasma glutathione peroxidase concentration did not correlate with gestational age or the presence of pre-eclampsia.

CONCLUSIONS

Plasma glutathione peroxidase expression is similar across all trimesters. There is no change in the glutathione peroxidase levels in pre-eclamptic patients.

Management of cervical cerclage at term: remove the suture in labor?

OBJECTIVE

To assess the risks and benefits to patients who carry to term after undergoing a Shirodkar cerclage where the cerclage is not removed until the patient presents in labor.

METHODS

A retrospective analysis was conducted examining all patients who underwent a Shirodkar cerclage employing a 5 mm Mersilene band. All the cerclages were placed by a single operator over a twenty five year span, from 1/01/74 till 10/01/98. Only patients who delivered vaginally or were allowed a trial of labor were included. In all cases, the cerclage was removed under regional anesthesia after the patient presented to the hospital in labor.

RESULTS

Ninety six cerclage procedures were performed over that period. Eighty two pregnancies qualified for review. Sixty two patients delivered vaginally (76%). Nine cesareans were indicated for failure to progress in labor (11%) with cervical dystocia possibly implicated in one. There were no cases of ruptured uteri or the development of uterine windows. Of the 82 pregnancies there were five cases (6%) of minor cervical laceration.

CONCLUSION

Allowing patients to proceed to labor with a Shirodkar, cerclage in place, does not increase the risks of cervical dystocia, cervical laceration, or uterine rupture above the reported incidence for these complications in patients in whom the cerclage is removed prophylactically.

In vitro reduction of peroxidation in UVC-irradiated cell cultures by concurrent exposure with Bowman-Birk protease inhibitor

Bowman-Birk protease inhibitor (BBI), extracted from soybean flour, has been shown to protect cells from damage after UVC irradiation. BBI also reduces the number of transformed foci following exposure to the same doses of UVC irradiation. Proteins have been reported to act as antioxidants by their sheer intracellular bulk. In this study we assessed BBI's ability to attenuate UVC-irradiation-induced peroxidation. Balb c/3T3 cells, clone A31, subcloned by this laboratory were used. Treatment groups consisted of cells suspended in Hanks' Balanced Salt Solution with and without 100 micrograms/ml of a crude soybean extract containing the Bowman-Birk protease inhibitor. Cells were exposed to irradiation in suspension by using GE (G8T5) germicidal lamps which deliver predominantly 254 nm light at 0.385 J/m2/s as measured at the cell surface. Aliquots of UVC-exposed cells were homogenized in HBSS in the presence and absence of 100 micrograms/ml BBI with a motor-driven Teflon pestle and assayed for peroxidation. The results showed significant (P less than 0.0001) protection afforded by BBI against peroxidation at 1.16 (65%), 1.93 (60%, and 2.70 (48%) J/m2 of UVC irradiation. Transformation was reduced to 0.33 foci per dish at all levels of radiation exposure.

A fluorometric method for measuring ethoxycoumarin O-deethylase activity by reversed-phase high performance liquid chromatography

A high-performance liquid chromatographic (HPLC) method that uses an on-line change in the protonation state of the nonfluorescent product to yield a fluorescent derivative that is detected by fluorometry was developed for the determination of 7-ethoxycoumarin O-deethylase activity. Tissue samples (1-20 micrograms protein) were incubated with 7-ethoxycoumarin, and 7-hydroxycoumarin metabolite was extracted in chloroform. Following drying under nitrogen, the extract was resuspended in methanol (10-100 microliters) and an aliquot of 5-20 microliters was directly injected into a C8 Nova-Pak column. Isocratic separation of hydroxycoumarin was achieved using a mobile phase consisting of methanol:1% acetic acid, 35:65, v/v, pH 3.5, at a flow rate of 1 ml/min. Following chromatographic separation, samples were derivatized with 1.0 N NaOH prior to fluorescent measurements. The detection limit for 7-hydroxycoumarin was less than 1 pmol, with a mean recovery from the incubates of 96.4 +/- 2.3%. This HPLC-fluorometric method was linear up to at least 400 pmol of 7-hydroxycoumarin and could accurately detect metabolite formation in incubates containing control liver microsomes with less than 0.05 microgram total protein. The method also allowed determinations of cytochrome P450-dependent function in extrahepatic tissues of rats, including individual segments of gastrointestinal epithelium and brain, as well as in cultured cells, such as HepG2 cells, in which microsomal protein yield is very small. The wide range of linearity afforded by this method allows a reliable estimation of cytochrome P450-dependent function in samples containing varying concentrations of protein.

Cadmium-induced alterations in ocular trace elements. Influence of dietary selenium and copper

The present report demonstrates, for the first time, that feeding rats 50 ppm cadmium for just 7 wk results in detectable levels of cadmium in the eye of rats. Furthermore, these ocular cadmium concentrations affect significant alterations in the levels of the essential trace elements selenium, calcium, iron, and copper in the eye. Rats were fed a low-selenium (less than 0.02 ppm selenium), high-copper basal diet (50 ppm copper) supplemented with 0, 0.1, and 0.5 ppm selenium. The animals were either untreated or treated with 50 ppm cadmium admixed with their feed. Cadmium treatment resulted in significant reductions (up to 50%) in ocular selenium. Furthermore, rats fed the basal diet and given 100 ppm cadmium via their feed for 6 wk exhibited a 69% reduction in the activity of the selenoenzyme, glutathione peroxidase, in the eye. Cadmium treatment also resulted in reductions of up to 50% in ocular calcium, irrespective of dietary selenium supplementation. Iron levels were increased by 30% in rats fed the low-selenium diet and decreased by as much as 40% in rats fed the selenium-supplemented diets, compared to animals fed identical levels of selenium without cadmium. Ocular copper levels were significantly increased only in rats fed the low-selenium diet and treated with cadmium. Ocular zinc levels were not significantly affected by dietary cadmium or selenium.