Pustular vasculitis of the hands

A case of pustular vasculitis of the hands with evidence of systemic involvement is described. A 64-year-old woman presented with a 2-day history of large, tense bullae arranged symmetrically over the dorsum of the three radial digits and extending on to the radial aspect of the dorsum of each hand. The bullae caused some discomfort and prevented normal use of her hands. There was no response to antibiotic therapy initiated prior to referral to hospital. Initial investigations revealed a raised white cell count with a neutrophilia, a raised erythrocyte sedimentation rate and a raised C-reactive protein. Abnormalities of liver function were detected. Aspirates from the bullae and blood cultures were sterile. The histology of debrided tissue demonstrated a florid neutrophilic dermal infiltrate with many blood vessels associated with prominent fibrin. A diagnosis of pustular vasculitis of the hands was made. The bullae were surgically debrided and treatment with oral corticosteroids was started. Two days after commencement of oral prednisolone, a crusted pustule appeared on her upper cutaneous lip. There was rapid resolution of both the vasculitis of the hands and the pustule on her upper lip following an increase in the dose of oral prednisolone. The patient was discharged on the seventeenth day following admission.

Granulomatous glomerulonephritis in intravenous drug users: a report of three cases in oxycodone addicts

Various well-documented renal lesions are associated with intravenous drug use; however, intraglomerular mesangial granulomas have not been previously described. We report three patients who developed an unusual granulomatous glomerulonephritis and interstitial nephritis after intravenous injection of oxycodone, derived from suppositories. Granulomas were seen in an intraglomerular mesangial and also interstitial location. In both sites, the granulomas were associated with filamentous material, presumably derived from a component of the suppositories. This material was periodic acid-Schiff-positive, but negative with Congo red and silver stains. Ultrastructurally, the filamentous material was seen within the mesangial granulomas and also in a subendothelial location, suggesting derivation from the circulation with subsequent transport across the basement membrane and accumulation in the mesangium, where a granulomatous reaction was elicited. All patients developed a degree of renal failure; two of the patients require hemodialysis 20 and 30 months after presentation.

Gastrointestinal bleeding from hepatocellular carcinoma invading the stomach

Bleeding from hepatocellular carcinoma (HCC) invading the gastrointestinal tract is very uncommon. We report the case of a 61 year old man who had a large bleed from HCC invading the fundus of the stomach. Diagnosis was eventually made at laparotomy and he is still alive 7 months after local resection.

The effect of malaria infection on primaquine elimination in the isolated perfused rat liver

Most antimalarial drugs are eliminated by hepatic metabolism. However, the influence of malaria infection on the hepatic elimination of these drugs has not been examined. In the present study the elimination of the antimalarial primaquine has been examined in isolated perfused rat livers (IPRL) of malaria-infected Sprague-Dawley rats (90-110 g) (MI group; N = 6) and age- and weight-matched healthy rats (control group; N = 7). IPRL preparations for the MI group were established 12-15 days after rats were infected with merozoites of Plasmodium berghei (150 X 10(6) parasites/ml; 0.2 ml i.p.). At the time of study there was marked variation in the degree of parasitaemia achieved in the rats used in the MI group, from 2 to 27% of erythrocytes being infected. Livers were isolated using standard techniques and perfused at 10 ml/min in a 100 ml recycling system for 4 hr. In the control group, the perfusate disappearance of primaquine was biphasic with a mean t1/2 beta of 0.77 +/- 0.10 hr. This was prolonged in the MI group (mean t1/2 beta = 1.06 +/- 0.09 hr; P less than 0.05). There was no significant difference in the volumes of distribution of primaquine between the MI group (mean = 320 +/- 73 ml) and the control group (mean = 284 +/- 79 ml). Although there was a trend to lowered primaquine clearance in the MI group (mean 217 +/- 26 ml/hr), it was not significantly different from that seen in the control group (mean = 277 +/- 42 ml/hr; 0.10 less than P greater than 0.05). However, there was an inverse linear correlation between primaquine clearance and the percentage parasitaemia (r = 0.722, P less than 0.05). These results suggest that the extent to which primaquine elimination had been compromised was related to the severity of malaria infection, and that in severe infections reduced efficiency of elimination raises the possibility of drug toxicity.

Chronic lymphatic leukemia developing in a patient with multiple myeloma: immunologic demonstration of a clonally distinct second malignancy

A patient with multiple myeloma who subsequently developed chronic lymphocytic leukemia is reported. Initial studies demonstrated clinical and hematological features of multiple myeloma with an IgM lambda paraprotein. Skeletal disease was a significant presenting feature, although relapse occurred in extraosseous sites, particularly the pleura. He developed chronic lymphatic leukemia 31 months later and immunological studies showed the malignant lymphocytes to have kappa (Kappa) light chain surface immunoglobulin, demonstrating separate clonal origin of this patient's two B-cell malignancies.

Multiple cranial nerve palsies as the presenting feature of meningeal myelomatosis

The case of a 69-year-old man with IgGK myeloma in whom meningeal myelomatosis with multiple cranial nerve palsies developed, is reported. Review of previously reported cases of clinically apparent meningeal myelomatosis indicates this rare complication frequently presents with cranial nerve palsies; currently available treatment is ineffective.

Plasma disappearance of intravenously injected radiolabelled glycocholic acid in patients with liver disease

The plasma disappearance of an intravenously injected tracer dose of glycocholic acid (glycine-1-14C) was compared in patients with and without diffuse hepatocellular disease. No difference was found between the two groups of patients. We conclude that this test is not a sensitive index of the presence of significant liver disease.

Giardiasis following gastric surgery

A patient is presented who developed acute life-threatening diarrhoea due to infestation with Giardia lamblia. We propose that the severity of the illness may have been related to hypochlorhydria following gastric surgery.

Human antibody against rat gastric parietal cells and kidney brush border

Antibodies cross-reacting with rat gastric parietal cells and the brush border of renal tubules have been demonstrated at a serum dilution of 1 in 5 in 14% of 262 human subjects. The highest incidence was found in patients with autoimmune thyroiditis (27%) or pernicious anaemia (22%); normal group AB blood donors showed an incidence of 18%. Studies with enzymes and solvents suggested that the antigen might be a protein, perhaps masked incompletely by lipid. The antibody also reacted with guinea-pig gastric parietal cells and kidney. The inability to react with human or mouse gastric parietal cells clearly distinguishes the antibody from that found commonly in patients with pernicious anaemia.

Rabbit antibodies reacting with brush border of rodent renal tubules

The immunofluorescent staining characteristics of antibodies against rat and mouse kidney tubule brush border, produced in rabbits immunized with microsomal or mitochondrial fractions of rat kidney, were compared with those of human antibodies against mitochondria obtained from patients with biliary cirrhosis. With the rabbit antisera, brush border staining was confined to the epithelium of the proximal renal tubules while the human antimitochondrial sera stained proximal and distal tubules. Absorptions with a mitochondrial fraction prepared from rat liver inhibited the human serum activity but had no effect on brush border activity in the rabbit serum which was inhibited only by the rat kidney subcellular fractions.