[Spontaneous bacterial peritonitis with Streptococcus constellatus in an HIV positive patient]

Liver diseases are an important cause of high morbidity and mortality in HIV-infected patients, and liver cirrhosis is the commonest cause of ascites in this population. We describe the case of a 38-year-old HIV-positive male (CDC stage B3, CD4 cell count 199/mm3) with a history of hepatitis C-associated liver cirrhosis. Following pneumonia he developed spontaneous bacterial peritonitis due to Streptococcus constellatus. Clinically noticeable was the gradually worsening course with few symptoms, despite the initially high ascitic fluid leucocyte count of over 11,000/microliter, but a favourable response to betalactam antibiotics.

[Interdisciplinary discussion about euthanasia--viewpoint of the clinical physicians]

In western cities more than 80% of deaths occur in the hospital. Thus, we should be familiar with the professional care for dying patients. However, reports of euthanasia in the Netherlands and interviews of patients in other countries demonstrate that medical care for patients with end stage diseases frequently is insufficient. The need for palliative care, which encloses medical, psychological, social and spiritual aspects of the dying becomes apparent. The physical symptoms (e.g. pain) are only one aspect of the suffering of the terminally ill. Following the WHO guidelines for use of analgesic drugs pain control is achieved in the majority of patients. Palliative care may individually tailor the treatment and care to achieve symptom control. Legalization of euthanasia will diminish the interest in practicing palliative care and may also limit the enthusiasm in research in this field as seen in the Netherlands. Data analysis report significant increase of physician-assisted suicide and euthanasia in the Netherlands within five years time from 1990 to 1995 (total: 3.7% to 4.7%, euthanasia: 1.7% to 2.4%). In addition, each year about 1000 patients were not competent at the time euthanasia was performed (euthanasia without request)! Furthermore, a patients illness did not have to be in end stage when he required euthanasia. This information should rise concern about future developments! The public enthusiasm for legalization of euthanasia in Switzerland may reflect the fear of dying and the belief that physicians and other medical professionals are not equipped to adequately care for the dying. Indeed, professional competence of palliative medicine to treat the symptoms of terminally ill patients particularly with cancer has frequently been insufficient. The majority of Swiss dying with assisted suicide (Switzerland belongs to the few countries where assisted suicide is not illegal) in 1996 and more than 80% in the Netherlands dying by euthanasia had cancer. For the terminally ill euthanasia and assisted suicide may seem the only solution. Enhancing education in palliative medicine is a necessary first step to improve the care for the dying patients.

Revival of tetracyclines--in the treatment of visceral leishmaniasis?

A 37-year-old immigrant from Kosovo who had been in Switzerland for 2 years developed fever, cough, weight loss and malaise. Serology (complement binding reaction) was positive for leptospirosis. The symptoms resolved very rapidly under vibramycin 2 x 100 mg/day for 3 weeks. However, a flare-up occurred after cessation of medication. Reexposure to tetracyclines improved the symptoms though they did not subside completely. Bone marrow analysis demonstrated intracellular leishmania (amastigotes). Analysis of frozen serum preserved since the first hospitalisation and samples from the second admission were positive for leishmania (indirect fluorescence antibody test) and confirmed the diagnosis of visceral leishmaniasis. Reevaluation of the serology for leptospirosis was negative using the specific microagglutination method. Treatment with antimony for 28 days resolved all symptoms. The parasites of visceral leishmaniasis grow intracellularly and eradication may be impossible in patients with an impaired cellular immune response. Flare-ups thus recur in 60-100% of patients with organ transplants or AIDS, despite regular treatment. Our finding raises the question whether relapses are suppressed in immunocompromised patients by tetracyclines, drugs known to be well tolerated even under long-term exposure. Randomised studies are required in this setting.

[Rhabdomyolysis and cholestatic hepatitis under treatment with simvastatin and chlorzoxazone]

Acute rhabdomyolysis under treatment with HMG-CoA reductase inhibitors ("statins") is a group-specific if rare side effect. Muscle toxicity of statins can be potentiated by medication influencing their metabolism. Here drug interactions on the level of the microsomal cytochrome P450 enzymes play an important role. We report the first case of marked rhabdomyolysis with cholestatic hepatitis in a 73-year-old woman treated with simvastatin and chlorzoxazone. Withdrawal of the causal medication and conservative therapy with volume substitution and forced diuresis was followed by almost complete resolution of the symptoms with normalisation of the blood tests. Possible mechanisms involved in the drug interactions are discussed. Thorough knowledge of the enzyme systems involved in drug metabolism helps to predict possible adverse drug interactions and prevent toxic effects.

Agonist-induced activation of a non-selective ion current in glomerular endothelial cells

The control of intracellular calcium activity ([Ca2+]i) and membrane voltage (Vm) play an important role in regulating functions of glomerular endothelial cells (GEC). We investigated the effect of extracellular ATP on the intracellular [Ca2+]i, Vm and ion conductances in GEC. ATP (100 mumol/liter) induced a rapid increase of [Ca2+]i in GEC from 20 +/- 6 to 442 +/- 84 nmol/liter, which was followed by a sustained Ca2+ plateau of 112 +/- 29 nmol/liter. In a bath solution with a low extracellular Ca2+ concentration the ATP-induced [Ca2+]i peak was still present, but the [Ca2+]i plateau was completely prevented. In 186 experiments with the patch clamp technique the addition of ATP (1 to 100 mumol/liter) to GEC induced a transient small hyperpolarization, which was followed by a depolarization. During the ATP-induced depolarization an increase of the whole cell conductance was found. The Ca2+ ionophore A23187 (10 mumol/liter) mimicked the effect of ATP on Vm. Reduction of the extracellular Ca2+ to 1 mumol/liter itself depolarized GEC reversibly from -88 +/- 2 to -60 +/- 12 mV and increased the ATP-induced depolarization to -18 +/- 3 mV. In the absence of Na+ in the bathing solution (replacement by NMDG+) ATP induced only an attenuated depolarization and no inward current was activated. Flufenamate (100 mumol/liter), a blocker of non-selective ion channels inhibited the ATP-induced depolarization of Vm significantly by 58 +/- 13%, whereas nicardipine (10 mumol/liter) or amiloride (10 mumol/liter) had no effect. Our data indicate that the resting Vm of GEC cells is almost completely dominated by K+ conductances and that ATP activates a Ca2+ dependent non-selective ion conductance in GEC.

Extracellular ATP regulates glomerular endothelial cell function

1. Glomerular endothelial cells form the inner part of the filtration barrier and are involved in pathophysiological processes in the glomerulum. New techniques for culturing glomerular endothelial cells have been established recently. The effect of extracellular ATP on membrane voltage and intracellular calcium activity was examined in bovine glomerular endothelial cells (GEC) in culture. 2. Membrane voltage was measured with the patch clamp technique in the fast whole cell configuration. GEC possess a stable membrane voltage of -88 mV. ATP induced a small transient hyperpolarization, which was followed by a depolarization. The ATP-induced depolarization was significantly inhibited by flufenamate, a blocker of non-selective ion channels. 3. The intracellular calcium activity [Ca2+]i was measured in single cells with the fura-2 technique. ATP stimulated an increase of [Ca2+]i. The increase of [Ca2+]i was biphasic with an initial peak followed by a sustained plateau. The [Ca2+]i peak was still present in an extracellular Ca(2+)-free solution, whereas the plateau was inhibited. 4. The order of potency of different purine nucleotides in stimulating [Ca2+]i and inositol formation was UTP = ATP > ATP-gamma-S > 2-methylthio ATP > [alpha,beta-CH2]ATP. 5. The data indicate that ATP regulates membrane voltage and [Ca2+]i in glomerular endothelial cells by a P2y2 receptor.

[Cell membrane receptors and intracellular signalling. Characterization in cultivated, contractile and endothelial cells]

Numerous hormones and mediators develop their effect via one or several specific receptors/subtypes. In glomerular endothelial cells (GEC), for example, the action of adenosine triphosphate is mediated by a novel nucleotide receptor. Since the latter is not found in large vessels, it is expected to play an important role in the regulation of the microcirculation. Substances with a very similar structure, such as vasopressin and oxytocin, can bind to the same receptor in vascular smooth muscle cells (VMC), although only the true agonist produces a maximum response. Following the binding of vasopressin to its specific V1-VP receptor, the ligand/receptor complex is internalized and processed within the cell. The freed receptor is then recycled to the cell membrane. This mechanism is responsible for the transient nature of vasopressin action. In VMC and the functionally similar contractile glomerular mesangial cells, vasopressin triggers intracellular signals, resulting in contraction. These signals may be enhanced or attenuated by numerous hormonal factors or mediators.

Cellular action and interactions of arginine vasopressin in vascular smooth muscle: mechanisms and clinical implications

In recent years, much has been learned about the vascular action of arginine vasopressin (AVP) including (1) the structure, internalization, and recycling of the V1 AVP receptor; (2) the AVP postreceptor signaling events for the initial and sustained vascular smooth muscle cell contraction as well as the hormone's mitogenic effect; (3) the process of homologous and heterologous AVP desensitization in vascular smooth muscle cells; (4) the interaction of AVP with other vasoconstrictor and vasodilator hormones; (5) the vascular interaction of AVP with endothelial events; and (6) the vascular interactions that may occur with systemic acidemia or alkalemia as well as with ethanol. The various potential clinical and biochemical implications of these results are discussed briefly.

[HIV infection caused by kidney transplant: case report and review of 18 published cases]

Since 1985 organ donors are routinely tested for the presence of HIV-antibodies, but prior to that time several patients acquired HIV-infection from grafts. In May 1984 a 65-year-old woman on hemodialysis received a cadaver kidney graft from a young iv drug addict. The transplant functioned perfectly with cyclosporin A immunosuppression. Retrospectively, 22 days after surgery HIV antigen was detected. At this time only a faint band of anti-p24 antibodies was found in the Western blot. Two years after surgery splenomegaly was found in the apparently healthy patient. During the third year thrombocytes fell and she developed lymphadenopathy and constitutional symptoms. Up to this time the immunological parameters were in the range of 10 healthy renal transplant patients with cyclosporin A treatment. In the 4th year T-lymphocytes dropped to values below 200 and the patient developed Pneumocystis carinii pneumonia. A few months later a pulmonary node, which later proved to be a B-cell lymphoma, appeared. Slightly less than 5 years after transplantation the patient died from clinically diagnosed pulmonary embolism. The progression of the HIV-Infection in this patient and in one of 18 patients in published reports show that the incubation period is several years shorter in renal transplant patients than in those who acquire HIV from blood products.

[Hereditary Poland syndrome with megacalycosis of the right kidney]

Poland's syndrome is characterized by congenital aplasia of the sternocostal head of the pectoralis major muscle associated with ipsilateral hand deformities (most often synbrachydactylia). 20% of patients have rib cage abnormalities, some with herniation of the lung. In some cases other associated ipsilateral anomalies (hypoplasia or absence of the nipple and/or the breast, defects of the vertebrae, dextrocardia, renal aplasia of hypoplasia, undescended testes, Möbius syndrome) have been described. We describe a patient with right-sided Poland's syndrome, the first published case associated with megacalycosis of the ipsilateral kidney. It is also the first publication of a familial case with this renal anomaly, since a brother has megacalycosis of the right kidney without Poland's syndrome. The majority of cases of Poland's syndrome are sporadic. The incidence has been estimated at between 1:30,000 and 1:80,000 of live births. The great uncle of our patient had a short forearm and only rudimentary fingers. The etiology of the syndrome is unknown. Toxic effects early in fetal life or effects on primary asymmetrical blood vessels, e.g. the subclavian artery, followed by uneven growth, are discussed as possible causes of Poland's syndrome.

[Acute rhabdomyolysis]

By damaging cell membrane integrity, acute rhabdomyolysis leads to electrolyte shifts according to the concentration gradients and the liberation of intracellular substances. Diagnosis is confirmed by the presence of a high serum creatinkinase activity (CK) and myoglobinuria. For clinical purposes myoglobinuria is demonstrated by a blood-positive dipstick in the absence of hematuria or hemoglobinuria. Rhabdomyolysis is usually acquired and is rarely due to hereditary enzyme defects. The authors report on 61 patients admitted in the last 15 years with rhabodomyolysis. In the past 4 1/2 years the diagnosis was suggested by CK greater than 5000U/1 in 49 patients, representing 1.6% of all admissions in the departments of medicine and surgery. Originally described in crush situations, rhabdomyolysis has been observed with increasing frequency as a consequence of muscular stress and self crush due to coma or hemi- and paraplegia during the last decades. 24% of the patients with this diagnosis had had an intoxication, and in 70% there were multiple simultaneous causes. Autoimmune diseases, infections of bacterial, viral and fungal origin, endocrinopathies, and thermic and ischemic injuries can also provoke rhabdomyolysis. As a consequence of fluid shift into the damaged muscle a compartment syndrome may lead to vascular or neural defects. In 80% of cases there is initial hypocalcemia, turning later into hypercalcemia. Other frequent electrolyte disorders accompanying rhabdomyolysis are hyperkalemia, hyperphosphatemia and a widened anion gap. 6 of 13 patients showed the typical blood changes found in patients with disseminated intravascular coagulation. Acute renal failure developed in 30 patients, 15 of whom underwent dialysis or hemofiltration.(ABSTRACT TRUNCATED AT 250 WORDS)

[New diagnostic and therapeutic aspects of acute kidney failure]

In a 20 months' period 20 patients were dialyzed at the Cantonal Hospital, Lucerne, because of acute renal failure (ARF). Contrary to expectation, the main cause was not circulatory failure but traumatic and nontraumatic rhabdomyolysis (5 patients), septicemia (9 patients) and endogenous and exogenous intoxications. In only 2 patients did shock seem an important factor in the pathogenesis of ARF. In view of the many causes of rhabdomyolysis, the frequency of patients with myoglobinuric ARF is hardly surprising. Case history, brown-colored urine with a positive reaction for hemoglobin in the absence of significant hematuria and without significant hemolysis (as judged by the color of the plasma or serum) and, most important, high creatine kinase (10(4) to 10(6) U/l) point to the correct diagnosis. In patients who had undergone trauma or surgery the main cause of ARF was uncontrollable infection. A long interval between the accident or operation and the onset of ARF was typical in these cases. Both hemodialysis and peritoneal dialysis are adequate methods of treatment for ARF. For technical reasons, however, in more than 50% of patients with ARF due to trauma or surgery, peritoneal dialysis is not feasible. On the other hand, in patients with cardiovascular instability continuous arterio-venous hemofiltration serves as an alternative to hemodialysis. With the introduction of Y-shaped dialysis catheters and the single needle system with double pump and controlled ultrafiltration, hemodialysis has become an easier and safer procedure. For patients with prolonged-course ARF the authors prefer a combination of initial hemodialysis, followed by peritoneal dialysis.(ABSTRACT TRUNCATED AT 250 WORDS)