Cardiac magnetic resonance imaging-indeterminate/negative cardiac sarcoidosis revealed by 18F-fluorodeoxyglucose-positron emission tomography: two case reports and a review of the literature

Background

Sarcoidosis is an inflammatory disorder of immune dysregulation characterized by non-caseating granulomas that can affect any organ. Cardiac sarcoidosis is an under-recognized entity that has a heterogeneous presentation and may occur independently or with any severity of systemic disease. Diagnosing cardiac sarcoidosis remains problematic with endomyocardial biopsies associated with a high risk of complications. Several diagnostic algorithms are currently available that rely on histopathology or clinical and radiological measures. The dominant mode of diagnostic imaging to date for cardiac sarcoidosis has been cardiac magnetic resonance imaging with gadolinium enhancement.

Case presentations

We report the cases of two adult patients: case 1, a 50-year-old white man who presented with severe congestive cardiac failure; and case 2, a 37-year-old white woman who presented with complete heart block. Both patients had a background of untreated pulmonary sarcoidosis. Cardiac magnetic resonance imaging did not show evidence of sarcoidosis in either patient and both proceeded to ¹⁸F-fluorodeoxyglucose-positron emission tomography scans that were highly suggestive of cardiac sarcoidosis. Both patients were systemically immunosuppressed with orally administered prednisone and methotrexate and had subsequent improvement by clinical and nuclear medicine imaging measures.

Conclusions

Current consensus guidelines recommend all patients with sarcoidosis undergo screening for occult cardiac disease, with thorough history and examination, electrocardiogram, and transthoracic echocardiogram. If any abnormalities are detected, advanced cardiac imaging should follow. While cardiac magnetic resonance imaging identifies the majority of cardiac sarcoidosis, early disease may not be detected. These cases demonstrate ¹⁸F-fluorodeoxyglucose-positron emission tomography is warranted following an indeterminate or normal cardiac magnetic resonance imaging if clinical suspicion remains high. Unidentified and untreated cardiac sarcoidosis risks significant morbidity and mortality, but early detection can facilitate disease-modifying immunosuppression and cardiac-specific interventions.

Quality assessment of groundwater from the south-eastern Arabian Peninsula

Assessment of groundwater quality plays a significant role in the utilization of the scarce water resources globally and especially in arid regions. The increasing abstraction together with man-made contamination and seawater intrusion have strongly affected groundwater quality in the Arabia Peninsula, exemplified by the investigation given here from the United Arab Emirates, where the groundwater is seldom reviewed and assessed. In the aim of assessing current groundwater quality, we here present a comparison of chemical data linked to aquifers types. The results reveal that most of the investigated groundwater is not suitable for drinking, household, and agricultural purposes following the WHO permissible limits. Aquifer composition and climate have vital control on the water quality, with the carbonate aquifers contain the least potable water compared to the ophiolites and Quaternary clastics. Seawater intrusion along coastal regions has deteriorated the water quality and the phenomenon may become more intensive with future warming climate and rising sea level.

Natural radioactivity in groundwater from the south-eastern Arabian Peninsula and environmental implications

Groundwater is the most valuable resource in arid regions, and recognizing radiological criteria among other water quality parameters is essential for sustainable use. In the investigation presented here, gross-α and gross-β were measured in groundwater samples collected in the south-eastern Arabian Peninsula, 67 wells in Unite Arab Emirates (UAE), as well as two wells and one spring in Oman. The results show a wide gross-α and gross-β activities range in the groundwater samples that vary at 0.01∼19.5 Bq/l and 0.13∼6.6 Bq/l, respectively. The data show gross-β and gross-α values below the WHO permissible limits for drinking water in the majority of the investigated samples except those in region 4 (Jabel Hafit and surroundings). No correlation between groundwater pH and the gross-α and gross-β, while high temperatures probably enhance leaching of radionuclides from the aquifer body and thereby increase the radioactivity in the groundwater. This conclusion is also supported by the positive correlation between radioactivity and amount of total dissolved solid. Particular water purification technology and environmental impact assessments are essential for sustainable and secure use of the groundwater in regions that show radioactivity values far above the WHO permissible limit for drinking water.

Prevalence of colorectal cancer associated with Streptococcus bovis among inflammatory bowel and chronic gastrointestinal tract disease patients

Colorectal cancer (CRC) is the second most common cause of cancer mortality among men and women worldwide; the risk of its occurrence has been shown to be increased by chronic bacterial infections. A case control study was therefore carried out at Hospital Universiti Sains Malaysia (HUSM) to determine the incidence of colorectal cancer associated with S. bovis infection. A total of 166 stool specimens were collected from diseased patients and healthy individuals and S. bovis isolates were identified. Suspected colon tumor and cancer cases were diagnosed and confirmed. It was found that overall prevalence of S. bovis was 41 (24.7%) out of 166 cases studied. Some 41(48.6%) of these S. bovis isolates was found in patients with colonic polyps, adenocarcinomas, inflammatory bowel disease (IBD) and chronic gastrointestinal tract (GIT). It was also found that colorectal cancer incidence was 24.7%, adenocarinomas accounting for 51% with the highest incidence in the sigmoid part of the colon. Among the IBD and chronic GIT cases, ulcerative colitis featured in the majority of cases (41.4%). In conclusion, there is a high incidence of colorectal cancer associated with S. bovis.

PTGS2-899G>C and prostate cancer risk: a population-based nested case-control study (ProtecT) and a systematic review with meta-analysis

Prostaglandin endoperoxidase synthase 2 is a key regulator of inflammation and may play a role in prostate carcinogenesis. The polymorphism, -899G>C (rs20417), alters a transcription factor-binding site and is associated with a reduced risk of colorectal adenoma. We tested the hypothesis that rs20417 may influence prostate cancer risk, using a large case-control study (n(cases)=1608, n(controls)=3058). We found no evidence that rs20417 alters prostate cancer risk (odds ratio (OR(CC & GC v GG)=1.05, 95% confidence interval (CI)=0.91-1.20). A meta-analysis of three studies also found little evidence that rs20417 alters risk (pooled OR(CC & GC v GG)=1.04, 95% CI=0.93-1.17), making it unlikely that rs20417 contributes in any major way to prostate cancer aetiology.

A subset of dorsal neurons modulates circadian behavior and light responses in Drosophila

A fundamental property of circadian rhythms is their ability to persist under constant conditions. In Drosophila, the ventral Lateral Neurons (LNvs) are the pacemaker neurons driving circadian behavior under constant darkness. Wild-type flies are arrhythmic under constant illumination, but flies defective for the circadian photoreceptor CRY remain rhythmic. We found that flies overexpressing the pacemaker gene per or the morgue gene are also behaviorally rhythmic under constant light. Unexpectedly, the LNvs do not drive these rhythms: they are molecularly arrhythmic, and PDF--the neuropeptide they secrete to synchronize behavioral rhythms under constant darkness--is dispensable for rhythmicity in constant light. Molecular circadian rhythms are only found in a group of Dorsal Neurons: the DN1s. Thus, a subset of Dorsal Neurons shares with the LNvs the ability to function as pacemakers for circadian behavior, and its importance is promoted by light.

[Differentiated treatment of acute infectious pulmonary destruction]

The results of treatment for pulmonary abscess and gangrene in 565 patients are analyzed. The treatment was conducted according to peculiarities of clinical course of the disease. The method of first choice is complex conservative treatment with performance of draining and delayed operations according to the indications.

[Orbitofrontal syndrome in psychiatry]

Orbitofrontal syndrome is a variant of frontal lobe syndrome in which behavioural disturbances are prevailing. It results from bilateral lesions of the orbitofrontal cortex and the medial face of frontal lobe. Patients present disorganized hyperactivity. They are distractable, impulsive, euphoric and unable to abide by social rules. They often have instinctive disinhibition (hypersexuality, hyperphagia and urinary behaviour disorders). In spite of severe behavioural disturbances cognitive functions are often intact so that orbitofrontal syndrome may be confounded with two psychiatric disorders: mania (or hypomania) and antisocial personality disorder. In this article we present a case report of orbitofrontal syndrome which was initially misdiagnosed as mania. Clinical features and possible modes of presentation of this syndrome are discussed. It is suggested that serotonin reuptake inhibitors may be of some use in this disorder.

Failure of a saphenous vein extracranial-intracranial bypass graft to protect against bilateral middle cerebral artery ischemia after carotid artery occlusion: case report

OBJECTIVE AND IMPORTANCE

We present the case of a patient who experienced bilateral middle cerebral artery infarctions after Hunterian ligation and trapping of a ruptured right cavernous aneurysm, despite a high-flow extracranial-intracranial bypass. This is a rare complication, and it highlights the need for further refinements in our understanding of the hemodynamic insufficiency created by major vessel sacrifice.

CLINICAL PRESENTATION

The patient was a 59-year-old woman who experienced multiple episodes of massive epistaxis before undergoing angiography, which revealed left internal carotid artery occlusion and an irregular right cavernous aneurysm. The patient was then transferred to our center for treatment. The patient was neurologically intact at presentation, and her epistaxis was controlled by nasal packing.

INTERVENTION

The patient underwent an extracranial-intracranial bypass from the external carotid artery to the M2 segment of the right middle cerebral artery, followed by trapping of the aneurysm. Despite evidence of graft patency, the patient experienced bilateral middle cerebral artery distribution infarctions after surgery.

CONCLUSION

Although extracranial-intracranial bypasses protect the majority of patients who undergo carotid artery ligation from ischemic complications, this case demonstrates that hemodynamic insufficiency can occur even with a high-flow saphenous vein graft. Better ways to quantitate the hemodynamic needs of the brain after major vessel sacrifice may facilitate matching of the revascularization strategy to the specific needs of each patient, thus further reducing the likelihood of ischemic complications.

Ovulation induction and ovarian tumours: the debate continues

OBJECTIVE

To critically review the published literature regarding the proposed association of ovarian stimulation and increased risk of ovarian tumors.

DESIGN

A medline search (1966-1997) was done to identify case reports and epidemiological studies relevant to the issue in question. Review articles and critical reappraisals in the form of comments on studies done were also used.

RESULTS

Various case reports, studies and review articles were identified as most relevant.

CONCLUSION

Despite a few studies showing an apparent association between ovulation induction and ovarian cancer, support for their results has not been forthcoming. From the available data a causal relationship is not substantiated. To settle this issue large prospective studies are needed. Meanwhile, close clinical surveillance of patients being treated with ovulation induction is required.

A pharmacoeconomic comparison of UFT and 5-FU chemotherapy for colorectal cancer in South America

The escalating role played by managed care organizations in the health-care system is reflected in the increased demand for cost-effectiveness analyses (CEAs) to assess the balance between economic impact and clinical efficacy. For example, the high incidence and costs associated with colorectal cancer in Latin America calls for a comprehensive economic evaluation to ensure appropriate allocation of limited health-care funds. In addition, the current call for a "societal" perspective of such analyses indicates the need for increased consideration of the concerns of both patient and health-care provider. The introduction of oral tegafur and uracil (UFT) provided the opportunity to evaluate the pharmacoeconomic advantage of the new agent compared with the standard fluorouracil (5-FU). Results of this study indicated an economic advantage for oral UFT vs a 5-FU-based regimen in the treatment of colorectal cancer in Brazil and Argentina. It was further noted that the mild toxicity profile of UFT reduced both the number of clinic visits and the need for venipuncture procedures. Noting that oral UFT may have a positive impact on quality of life in addition to its estimated economic benefit, it was concluded that prospective economic research and quality-of-life evaluations are needed to fully assess the pharmacoeconomic impact of oral UFT.

Maturation of the goldfish (Carassius auratus) erythrocyte

1. Cohorts of [3H]thymidine-labelled erythrocytes were examined over a 42-day period in goldfish (Carassius auratus L.) recovering from phenylhydrazine HCl-induced anemia under normoxic conditions at 20 +/- 1 degree C and maintained with minimal disturbance on a high nutritional plane. 2. As judged by changes in primary and derived hematological variables, maturation required 16-20 days. 3. Similar estimates were obtained using cytomorphic variables obtained by image analysing methods. 4. These suggest that juvenile red cells in this species can be identified on the basis of the following characteristics: major axis less than 9.2 microM; one-sided surface area not greater than approximately 50 microns2; axis ratio greater than 0.774; form factor greater than 0.938. 5. Corresponding values for mature cells are: major axis greater than 11.2 microns; area greater than 68.5 microns2; axis ratio less than 0.716; form factor less than 0.912. 6. These criteria, with values for dividing and karyorrhectic cell numbers, offer a basis for more detailed and dynamic characterization of the erythron during response to environmental variation than has previously been possible.

Hematological characterization of goldfish, Carassius auratus L., by image analysis: effects of thermal acclimation and heat shock

The morphological characteristics of erythrocyte populations from goldfish, Carassius auratus L., acclimated to constant (15, 25, or 35 °C) and diurnally cycling (25 ± 10 °C) temperature regimes or exposed to abrupt heat shock (15–25 °C, 25–35 °C) were examined by image analysis in an attempt to develop criteria for assessing the stage of development and red cell population age structure. Of the indices considered, nuclear form factor (4π area/perimeter2) appeared to best define the immature state. Estimates of juvenile cell abundances based on nuclear form factor ranged from 23.2 to 56.5% of the cell population and were generally consistent with the thermal histories of the test groups examined. Erythrocyte population characterization is recommended for inclusion in future studies on hematological features of response to altered environmental conditions.

Effect of hypoxia on hemoglobin isomorph abundances in rainbow trout, Salmo gairdneri

To further assess the hypothesis that differential hemoglobin isomorph formation may be involved in the respiratory response of rainbow trout (Salmo gairdneri), yearling animals were first rendered acutely anemic by immersion in phenylhydrazine HCl. Erythropoiesis was then induced by gradual warming under normoxic and hypoxic conditions. While no significant differences in hemoglobin content were observed, trout exposed to hypoxia displayed transient, but significant differences in hematocrit. Significant variations in both the occurrence and abundance of specific isomorphs were also observed.

Induction of anemia in goldfish, Carassius auratus L., by immersion in phenylhydrazine hydrochloride

Immersion of goldfish, Carassius auratus, in 1 mg∙L−1 phenylhydrazine hydrochloride at 5 °C for 48 h led to reductions of 90–95% in hemoglobin and hematocrit within 10–14 days. Under similar conditions, 96-h exposures prompted heavy mortality. Fewer mortalities occurred after 24-h exposure periods; however, only modest reductions in O2-carrying capacity were seen. All higher concentration (2, 5, 10, 50 mg∙L−1) and temperature (10, 15, 20 °C) combinations led to complete mortality within 12–96 h regardless of exposure period (24, 48, 96 h). Exposure to phenylhydrazine hydrochloride caused decreases in hemoglobin and hematocrit, changes in the abundances of specific hemoglobin isomorphs, and the transient appearance of novel hemoglobin mobilities as well as evidence of osmo- and iono-regulatory dysfunction. Slow warming to 20 °C prompted red cell proliferation and hemoglobin synthesis and restoration of typical hemoglobin isomorph abundances. Incidence of transfer stresses was monitored by reference to differential leucocyte counts. Transfer led to lymphopenia and thrombopenia with neutrophilia and eosinophilia. Warming was accompanied by increases in lymphocyte and thrombocyte counts and reductions in those of monocytes and all granulocytes.