Refractory pituitary granulomatosis with polyangiitis (Wegener's) treated with rituximab

OBJECTIVE

Granulomatosis with polyangiitis (GPA), also known as Wegener's granulomatosis, is an autoimmune disease characterized by inflammation of blood vessels most often seen in the upper respiratory tract, lungs, kidneys, and skin. Central nervous system (CNS) involvement of GPA is rare, particularly in the pituitary, and can be difficult to treat.

METHODS

Case report.

RESULTS

We present a 30-year-old woman with pituitary and ocular GPA, whose unusually recalcitrant disease led to the development of pan-hypopituitarism and near-total vision loss. After failing multiple systemic immunosuppressants, she was ultimately treated with the novel immunomodulatory agent rituximab together with pulse corticosteroids, which achieved a gratifying response.

CONCLUSION

Pituitary and optic chiasm involvement is a rare complication of GPA. We believe this case illustrates the complexity of management of pituitary GPA and provides insight into the potential utility of the biologic agent rituximab in this disease.

Dysplastic-reactive choroid plexus presenting as an intramedullary tumor of the cervicomedullary junction in a patient with myelomeningocele

Dysplastic structural lesions within the fourth ventricle have been reported in patients with Chiari malformation type II (CM-II). The authors report the unique case of a 22-year-old patient with myelomeningocele who presented with progressive pain, decreasing hand function, and lower cranial nerve dysfunction in the context of a slowly enlarging intramedullary mass at the cervicomedullary junction. At surgery a multinodular mass attached to caudally displaced fourth ventricle choroid plexus was completely removed from an expanded central canal. The histopathological findings were consistent with dysplastic-reactive choroid plexus. Postoperatively the patient experienced relief of pain and improvement in hand strength. To the authors' knowledge, this is the first reported case in which dysplastic fourth ventricle choroid plexus was displaced caudally through the obex to become an intramedullary lesion at the cervicomedullary junction. Its subsequent slow enlargement with progressive neurological deficits may have been secondary to reactive inflammatory changes. For patients with myelomeningocele and CM-II, intramedullary dysplastic-reactive choroid plexus should be included in the differential diagnosis of mass lesions in this location.

HIV-2 encephalitis: case report and literature review

We report the case of a 59-year-old man who moved from Cape Verde to Massachusetts at the age of 29. He had multiple sexual contacts with female partners in Cape Verde and with West African women in Massachusetts, as well as multiple past indeterminate HIV-1 antibody tests. He presented to our facility with 2-3 months of inappropriate behaviors, memory impairment, weight loss, and night sweats, at which time he was found to have an abnormal enhancing lesion of the corpus collosum on brain magnetic resonance imaging (MRI). Laboratory testing revealed a CD4 count of 63 cells/mm(3), positive HIV-2 Western blot, serum HIV-2 RNA polymerase chain reaction (PCR) of 1160 copies per milliliter and cerebrospinal fluid (CSF) HIV-2 RNA PCR of 2730 copies per milliliter. Brain biopsy demonstrated syncytial giant cells centered around small blood vessels and accompanied by microglia, which correlated with prior pathologic descriptions of HIV-2 encephalitis and with well-described findings of HIV-1 encephalitis. Based on genotype resistance assay results, treatment guidelines, and prior studies validating success with lopinavir-ritonavir, he was treated with tenofovir-emtricitabine and lopinavir-ritonavir, which has led to virologic suppression along with steady neurologic and radiologic improvement, although he continues to have deficits.

Automated cerebrospinal fluid cell counts using the Sysmex XE-5000: is it time for new reference ranges?

The main objectives of the study were to compare manual and automated WBC counts on clear cerebrospinal fluid (CSF) samples. Clear CSF samples from 200 adults and children were studied. Cell counts were performed manually using a hemocytometer and then analyzed on the Sysmex XE-5000. Descriptive statistics and Spearman correlation for nonparametric data were used for method comparison. Manual WBC counts ranged from 0 to 702 cells/μL, and Sysmex counts ranged from 0 to 629 cells/μL. The Spearman rank correlation coefficient for the entire range of data was 0.77 (P < .001); however, the correlation was weaker at the low end of the data spectrum. For manual WBC ranges of 0 to 5 cells/μL and 0 to 10 cells/μL, the corresponding Sysmex 0 to 95th percentile ranges were 0 to 23 cells/μL and 0 to 27 cells/μL, respectively. The results suggest that larger studies are necessary to determine new reference ranges for automated CSF WBC counts.

Dependence of temporal variability of ventricular recovery on myocardial fibrosis. Role of mechanoelectric feedback?

OBJECTIVE

The study was aimed at establishing the effect of factors involved in the expression of mechanoelectric feedback in the heart, such as R-R interval and connective tissue, on time dependent changes in ventricular recovery, as determined at the body surface by beat to beat variability of QRST integral maps (BBV-IM).

METHODS

We used 15 normal 6-month-old Wistar rats. In each anesthetized animal, we performed a 3-minute continuous recording of 44. The simultaneous chest ECGs. The signals were interactively processed, 1) to determine mean R-R interval and R-R variability throughout the recording period and 2) to compute QRST integral maps from approximately 50 beats belonging to the end of expiration. Then BBV-IM was calculated and expressed as percentage of beats significantly differing from a template. At sacrifice, the amount of myocardial fibrosis was morphometrically evaluated.

RESULTS

R-R interval was 149 ms +/- 4, R-R interval variability 0.008 +/- 0.001 and BBV-IM 30.7% +/- 4.4. Myocardial fibrosis expressed as % volume of left ventricular myocardium, numerical density of fibrotic foci and average cross-sectional area of the foci was 3.0% +/- 0.4, 3.8 +/- 0.6 and 4.4 microns(2)/1000 +/- 0.1 respectively, BB-IM was positively correlated to the % volume of fibrosis (r = 0.83, P < 0.0003). Both measurements were positively correlated to R-R interval (BBV-IM: r = 0.83, P < 0.0001; % volume of fibrosis: r = 0.87, P < 0.001) and negatively correlated to cardiac weights (BBV-IM: r = -0.79, P < 0.0005; % volume of fibrosis: r = -0.75, P < 0.001).

CONCLUSION

Beat to beat changes in ventricular repolarization attributable to mechanoelectric transduction can be detected at the body surface by means of BBV-IM.

Comparison of electrocardiographic data (P waves): test of a shape-based approach

We tested a method for comparing ECG signals (P waves), in a sample of 10 normal males. In each subject, sets of 219 body surface ECGs were simultaneously recorded during tidal respiration. Only beats at end expiration and peak inspiration were considered. The beats of each group were subdivided into two subgroups of the same size (about 30 beats) and separately averaged. The two averaged beats at end expiration, assumed to be equal, were compared in order to estimate the noise variance (sigma2), i.e., the lowest value of variance at which the beats were statistically similar (P less than 0.05). At the same value of sigma2, the beat at end expiration significantly differed from that at peak inspiration. By considering the individual leads, significant differences were found in more than 50% of the 219 ECGs, in specific thoracic areas. The data indicated that the method can reveal differences between P waves occurring during tidal respiration and provide information on the topographical distribution of the differences.

A recursive algorithm to compute the baseline drift in recorded biological signals

Baseline estimation and removal is one of the main problems to overcome in order to obtain a correct interpretation of recorded biological signals. The method described in this paper is based on a new application of recursive estimation of a smoothing spline, selected to model the unknown baseline. Its advantages over conventional methods derive from these characteristics: it is parametric and recursive, it works in the time domain, and the same software can be used in different applications, since no a priori frequency knowledge is needed. In the example, the method is applied to ECG recordings and a spectral analysis is thereby shown.

Newer data on the configuration and variability ranges of body surface maps in a sample of normal subjects

Quantitative data on the normal variability of body surface maps (BSM) are scarce in the literature. This is one of the reasons why BSM are not yet widely used in clinical practice despite their superior information contents. In this study we determined the average value and variability of a number of parameters derived from BSM in a group of 36 normal adult males, ages 22 to 60. Forty to 60 homogeneous beats were averaged for each subject. This enabled us to extend our study to the low voltage intervals (P,PQ,ST,U) which encompass more than 60% of the entire P-U duration and to contribute new data to controversial issues, such as the presence of two simultaneous maxima during atrial excitation. The following parameters were measured: a) the coordinates of the absolute potential maximum and minimum on the chest surface during the entire cardiac cycle; b) the time course of four voltage-related functions, namely: highest instantaneous potential value on the chest surface, lowest (most negative) potential, highest potential difference, and surface integral of the absolute value of the potential function. In recent studies these parameters were shown to be of considerable value in discriminating normal subjects from different categories of cardiac patients.