Sweet Syndrome and Secondary Syphilis in a Person with Acute Necrotizing Tonsillitis.

Syphilis has received its classical designation as one of "the great imitators," reflecting a wide variety of symptoms and presentations, which can cause difficulties in diagnosis. Here we report an unusual case of secondary syphilis in a person with acute necrotizing tonsillitis and Sweet syndrome. A 33-year-old female presented with fever, bilateral cervical lymphadenopathy, tonsillar enlargements with ulcerated pus-filled lesions on the right tonsil, and multiple pseudovesicular, mammillated, edematous plaques on her neck, face, and extremities. Syphilis serology was positive and a skin biopsy demonstrated a neutrophil-rich dermatitis characteristic of Sweet syndrome. The association of Treponema pallidum infection with Sweet syndrome may be a coincidence; nevertheless, our case serves as a reminder that secondary syphilis should remain in the differential diagnosis of the acute febrile neutrophilic dermatosis.

Spontaneous Pathologic Splenic Rupture in a Patient with Plasmodium falciparum Infection, First Case Reported in Israel.

Travelers exposed to malaria may develop severe disease and complications. A less well-known complication is spontaneous pathologic splenic rupture, which is still under-reported and has never been reported in Israel. In this paper, we report a 23 years old healthy young man presenting in the emergency department, two weeks after coming back from Sierra Leone, with intermittent fever, mild tachycardia and mild left upper quadrant abdominal pain. The patient was diagnosed with Plasmodium falciparum infection and developed rapidly after hospital admission spleen rupture. He was managed conservatively at first but ultimately underwent splenectomy after being hemodynamically unstable. In the recovery period, the patient developed acute respiratory distress syndrome and was reintubated. A high level of suspicion is recommended in every malaria patient presenting with left upper quadrant abdominal pain, even if minimal. Ultrasonography availability in the internal medicine department may be a critical diagnostic tool, especially in non-endemic areas.

Septic Shock and Multiple Organ Failure After Office Endometrial Sampling.

BACKGROUND: Office endometrial biopsy with a Pipelle cannula is the main method for sampling the endometrial lining. The Pipelle biopsy is safe, efficient, and cost effective. This office endometrial sampling method is also an accurate and safe procedure for endometrial sampling of patients with endometrial carcinoma. It is associated with minimal pain and does not require anesthesia. CASE: Pipelle is the most common method used for sampling the endometrial lining. No data are available of infectious complications related to endometrial biopsy. The incidence is presumed to be negligible. We present an unusual case of a 52-year-old woman who experienced septic shock and multiple organ failure following Pipelle endometrial sampling. CONCLUSION: Lower abdominal pain is the cardinal presenting symptom in woman with pelvic infection. Our case emphasizes that an atypical symptom such as abdominal pain after endometrial biopsy could be a sign of infectious complications.

The clinical and laboratory characteristics of acute spontaneous urticaria and its progression to chronic spontaneous urticaria.

BACKGROUND: The natural history of the progression from acute spontaneous urticaria (ASU) to chronic spontaneous urticaria (CSU), CSU remains poorly understood. OBJECTIVE: To identify clinical and laboratory patient attributes that may be predictive of ASU progression to CSU. METHODS: We prospectively studied consecutive adult patients (age ≥ 18 years) with a diagnosis of urticaria of <6 weeks' duration. Healthy age- and sex-matched subjects served as controls. At study entry, autologous serum skin test (ASST), complete blood cell count, erythrocyte sedimentation rate, thyroid function tests, antinuclear antibodies, antithyroglobulin and antiperoxidase antibodies, and immunoglobulin E level were assessed in all the subjects. ASST and urticaria activity score assessment were performed in all the patients at baseline and then at weeks 7, 12, 24, and 48. RESULTS: Of 114 patients with acute urticaria and without identifiable causes, 73 patients (64%) were included in the ASU group, 41 patients in the CSU group (36%), and 44 healthy subjects in the control group. At baseline, 26 patients in the CSU group (63.4%) had a positive ASST result, whereas only 17 patients with a positive ASST result (23.3%) were revealed in the ASU group (p < 0.001). Patients with baseline ASST positive results were characterized by more profound basopenia (mean [standard deviation], 0.05 ± 0.08 cell/mm(3)) and more anti-thyroid peroxidase antibodies (18 [41.8%]) than those with the negative baseline ASST result (mean [standard deviation], 0.13 ± 0.09 cell/mm(3), p < 0.001 more profound basopenia; and 13 (18.1%), p = 0.009 more thyroid peroxidase antibodies). We observed the disappearance of ASST positive result in some patients with CSU with baseline positive ASST results, whereas, in some subjects with CSU, baseline negative ASST results came to be positive results throughout the study period. A baseline positive ASST result of patients with ASU was a significant determinant (odds ratio 5.91 [95% confidence interval, 2.57-13.62]; p < 0.001) for a CSU diagnosis at week 7. CONCLUSION: The patients with ASU who progressed toward CSU were characterized by a positive ASST result, thyroid autoimmunity, and profound basopenia at baseline.

Selective IgE deficiency and cardiovascular diseases.

Selective immunoglobulin E (IgE) deficiency (IgED) is defined as serum levels of IgE more than or equal to 2 kIU/L and is associated with immune dysregulation and autoimmunity. This study aimed to investigate a prevalence of atherosclerotic cardiovascular disease (ASCVD) in population with IgED. Within the electronic patient record (EPR) database of Leumit Health Care Services (LHS) in Israel, data capture was performed using IBM Cognos 10.1.1 BI Report Studio software. The case samples were drawn from the full study population (n = 18,487), having any allergy-related symptoms and/or those requesting antiallergy medications and performed serum total IgE measurement during 2012 at LHS. All subjects aged more than or equal to 40 years old, with serum total IgE less than 2 kIU/L were included in case group. Control group was randomly sampled from the remained subjects, with a case-control ratio of 10 controls for each case (1:10). The comorbid cardiovascular diseases during less than or equal to 10 years before serum total IgE testing were identified and retrieved using specific International Classification of Diseases, 9th Revision, Clinical Modification diagnostic codes. There were 103 in case and 1030 subjects in control group. Compared with control group patients, the case group had significantly more arterial hypertension [34 (37.7%) versus 187 (18.2%), p < 0.001], ischemic heart disease (IHD) [26 (25.2%) versus 87 (8.4%), p < 0.001], carotid stenosis [5 (4.9%) versus 7 (0.7%), p = 0.003], cerebrovascular disease (CVD) [3 (2.9%) versus 5 (0.5%), p = 0.029], and peripheral vascular disease (PVD) [4 (3.9%) versus 9 (0.9%), p = 0.024]. IgED is associated with higher prevalence of arterial hypertension and ASCVD.

Clinical and laboratory features of chronic idiopathic urticaria in the elderly.

BACKGROUND: There are few data regarding epidemiology and clinical features of urticarial diseases in the elderly population. OBJECTIVE: The aim of the study was to determine the clinical and laboratory characteristics of chronic idiopathic urticaria (CIU) in the geriatric population. METHODS: Electronic medical records of outpatient allergy consultations due to a diagnosis of CIU were retrospectively reviewed to collect demographic data, urticaria activity score, results of autologous serum skin test (ASST), and laboratory workup. RESULTS: From 1598 patients with chronic urticaria, there were 1319 (82.5%) adult (adult CIU group) and 124 (9.4%) elderly subjects (elderly CIU group). The elderly CIU group was characterized by lower prevalence (46.7%) of women compared to the adult CIU group (69.2%; P = 0.022); fewer wheals (1.4 ± 0.5) vs. (2.3 ± 0.7; P < 0.001); lower rates of concomitant symptomatic dermographism 2 (2.2%) vs. 121 (12.6%; P = 0.003); and lower rates of angioedema, 3 (14.1%) vs. 362 (37.8%; P < 0.001). Fewer elderly patients with CIU (18.1%) than adult patients with CIU (44.7%; P = 0.019) demonstrated a positive ASST. There were no differences in laboratory data between the study groups. CONCLUSION: CIU in the elderly population is nearly equally distributed in both sexes and is characterized by fewer wheals, lower rates of concomitant symptomatic dermographism, lower rates of angioedema, and lower ASST positivity.

The effect of L-thyroxine treatment on chronic idiopathic urticaria and autoimmune thyroiditis.

Autoimmune thyroiditis (AT) is more prevalent in patients with chronic idiopathic urticaria CIU) than in the general population. Previous small studies without any controlled comparison reported that CIU remits in patients with CIU and AT treated with L-thyroxine. To determine whether l-thyroxine treatment can improve the clinical course of CIU in patients with the co-occurrence of AT and CIU. A total of 749 patients with CIU were retrospectively studied. Clinical and laboratory evaluation and classification of chronic urticaria were performed according to the EAACI/GA(2)LEN/EDF/WAO guidelines. After L-thyroxine treatment for 53 ± 19 days, euthyroidism was restored in all subjects. Urticaria activity score (UAS) was evaluated at baseline and after three and six months. The control group consisted of matched 44 euthyroid subjects with CIU. A total of 44 (5.9%) patients were diagnosed to have hypothyroidism related to AT. Autologous serum skin test (ASST) was found to be positive in 17 (38.6%) of them. There was no statistically significant difference in baseline UAS, between the ASST+ (3.94 ± 1.52) and the ASST- (3.63 ± 1.42; P = 0.27) hypothyroid subjects and the euthyroid CIU controls (3.73 ± 1.74). During the L-thyroxine treatment, a significant reduction of UAS was observed in both hypothyroid ASST+ and ASST- subjects. However, the mean UAS after three and six months of L-thyroxine treatment remained not significantly different from that in control euthyroid subjects with CIU. L-Thyroxine treatment has no effect on the course of CIU in patients with CIU and AT.

Antihistamines do not inhibit the wheal induced by the intradermal injection of autologous serum in resistant chronic idiopathic urticaria.

Some patients with chronic idiopathic urticaria (CIU) are resistant to conventional doses of antihistamines (AHs). This study was designed to check whether the skin wheal and flare reaction produced by the intradermal injection of autologous serum (AS) and by histamine differs in AH-resistant and AH responder CIU patients. CIU patients with treatment failure under fexofenadine at 180 mg q.d. increased their daily dose of AH to 4 tablets daily. Those with significant improvement of urticaria activity score under fexofenadine at 180 mg were included in the CIU group. Subjects with treatment failure despite a full 8-week fourfold fexofenadine treatment were included in the resistant CIU (R-CIU group). The control group consisted of sex- and age-matched patents with allergic rhinitis. The AS skin test and intradermal histamine-induced wheal and flare reaction were performed at baseline (without AH), after 8 and 16 weeks (under AH treatment). Forty-six subjects were included in the CIU group, 21 were in the R-CIU group, and 44 were in the control group. Under AH therapy, the skin reaction to intradermal histamine injection was significantly diminished in all study groups. In the R-CIU group, fexofenadine at 180 mg did not suppress AS-induced wheal reaction (5.96 ± 2.25 mm; p = 0.85), and with a fourfold AH dose some reduction of AS-induced wheal (3.79 ± 1.74 mm; p = 0.008) was observed but remained larger than in the CIU (2.31 ± 1.12; p = 0.006) and control groups (2.52 ± 1.36; p = 0.037). AHs do not inhibit the wheal induced by the intradermal injection of AS in R-CIU.

Impact of contact sensitization in chronic spontaneous urticaria.

INTRODUCTION: Patch testing is performed to diagnose allergic contact dermatitis to avoid exposure to the revealed contact allergens. Nevertheless, patch testing is not routinely performed in the evaluation of patients with chronic idiopathic (spontaneous) urticaria (CIU). The objective of this study was to determine the frequency of sensitization to patch test allergens in severe CIU and assess a role of the allergen avoidance in CIU remission. METHODS: The cases of patients with severe CIU were retrospectively studied. The patients were patch tested using T.R.U.E. TEST. Three groups were studied: CIU with positive patch test group; CIU with negative patch test group and control group, which included the cases of not patch-tested patients with CIU. The groups were followed up monthly to assess changes in Chronic Urticaria Severity Score (CUSS) after allergen avoidance. RESULTS: Forty-three subjects with severe CIU were patch tested. Nickel sulphate was positive in 4 (9.3%) cases, potassium dichromate in 2 (4.7%) cases, cobalt, balsam of Peru, paraphenylene diamine, fragrance mix and epoxy resin were positive in 1 (2.3%) case. Their baseline CUSS (5.4 ± 0.5) improved significantly after 1 month of allergen avoidance (3.2 ± 1.1; P < 0.001); but similar improvement of CUSS (5.3 ± 0.5) was seen in 34 patients with CIU with negative patch test (3.2 ± 1.3; P < 0.001) and in 49 patients with CIU of control group (5.2 ± 0.4 to 3.4 ± 1.3; P < 0 < 0.001) after 1 month. CONCLUSIONS: There is no relationship between avoidance of contact allergens and the course of CIU.

Clinical and laboratory features of antihistamine-resistant chronic idiopathic urticaria.

Chronic idiopathic (spontaneous) urticaria (CIU) is sometimes resistant to the conventional and high doses of antihistamines (AHs). This study compares the clinical and laboratory characteristics of AH responsive and AH-resistant CIU subjects. Clinical and laboratory data were retrospectively collected from 385 CIU patients. Urticaria activity score (UAS), concomitant angioedema, dermatographism, positive autologous serum skin (ASST), and laboratory data were collected. The control group consisted of 44 sex- and age-matched healthy individuals. Two hundred forty-five CIU patients controlled with AH medications were included in the CIU group. Forty-six patients failed to show clinical improvement during 8 weeks of treatment with fourfold AH doses and were included in the resistant CIU (R-CIU) group. The R-CIU group was characterized with a higher incidence (58.7%) of angioedema than the CIU group (28.5%; p < 0.001), more cases concomitant physical urticaria (23.9% in R-CIU versus 12.2% in CIU; p = 0.014), more positive ASST (73.9% in R-CIU versus 45.4% in CIU; p < 0.001), and higher baseline UAS (5.28 ± 0.81 in R-CIU versus 3.32 ± 1.25 in CIU; <0.001). R-CIU was characterized with more severe basopenia (0.04 ± 0.07 cell/mm(3) versus 0.16 ± 0.13 cell/mm(3); p < 0.001), higher mean platelet volume (10.87 ± 2.21 femtoliter (fl) versus 8.65 ± 1.74 fl; p < 0.001), higher levels of C-reactive protein (8.62 ± 3.91 mg/L versus 2.49 ± 1.34 mg/L; <0.001), and higher levels of serum C3 (1.66 ± 0.36 g/L versus 1.19 ± 0.35 g/L; p < 0.001. R-CIU is a clinically more severe disease with laboratory features of low-grade inflammation and platelet activation.

Potential link between C3a, C3b and endothelial progenitor cells in resistant hypertension.

INTRODUCTION: Endothelial progenitor cells (EPC) and complement C3 are involved in the pathophysiology of arterial hypertension. C3a is the negative regulator of progenitor cells egress during their mobilization from bone marrow. Previously, higher plasma concentration of C3 was observed in resistant arterial hypertension (RAH) than in controlled arterial hypertension (CAH). Thus, we hypothesized that RAH would be associated with complement C3 activation and reduced number of circulating EPCs. OBJECTIVE: To compare C3a, C3b and their correlation with circulating EPC in subjects with RAH and CAH. METHODS: Blood pressure was measured by electronic sphygmomanometer. EPCs were identified as CD34+/CD133+/KDR+ cells by flow cytometry. C3a and C3b were determined using enzyme-linked immunosorbent assay (Quidel, CA). RESULTS: : RAH group (n = 20) and CAH group (n = 20) and 17 healthy individuals (control group) were recruited. In the RAH group, C3a (858.1 +/- 70.6 microg/dL) was higher than in the CAH group (816.1 +/- 123.3 microg/dL; P < 0.001), and in the control group (751.3 +/- 98.8; P < 0.001), C3b (564.1 +/- 54.7 microg/dL) was higher than in the CAH group (490.2 +/- 58.5 microg/dL; P < 0.001). In control group (456.3 +/- 98.8; P < 0.001), statistically significant negative correlation was observed between C3a and blood levels of EPC (r = -0.523, P = 0.018); statistically significant positive correlation was observed between systolic blood pressure and blood levels of C3a (r = 0.52, P = 0.02) and between systolic blood pressure and blood levels of C3b (r = 0.57, P = 0.009). CONCLUSION: RAH is characterized by higher levels of C3 component fragments and a negative correlation between circulating C3a and EPCs.

Increased mean platelet volume and C-reactive protein levels in patients with chronic urticaria with a positive autologous serum skin test.

INTRODUCTION: Activation of the coagulation cascade resulting in thrombin production is a prominent feature of exacerbations in chronic spontaneous urticaria (CU). Autologous serum skin test (ASST) causes wheal-and-flare reactions in 30% to 50% of CU cases. OBJECTIVE: The aim of this study was to evaluate the clinical and laboratory data in patients with CU with positive and negative ASST. To understand the role of platelets in CU, we investigated the relation between CU clinical severity, platelet count and their mean platelet volume (MPV). METHODS: Clinical and laboratory data were prospectively collected from 373 patients with CU who attended our Allergy and Clinical immunology Clinic during the period 2003 to 2007. The laboratory data were compared with 46 healthy subjects. RESULTS: There were no significant differences in platelet counts between the groups, nevertheless the platelets in ASST-positive CU patients were characterized by a higher MPV (9.12 +/- 1.25 fl), than that in ASST-negative patients (7.95 +/- 1.08 fl; P = 0.039) and control group (7.72 +/- 1.04 fl; P = 0.007). There was a significant positive correlation between CU severity score and MPV in ASST-positive patients (r = 0.44; P < 0.001) but not in ASST-negative patients. Higher levels of C-reactive protein (5.31 +/- 2.74 mg/L) were measured in the ASST-positive CU group compared with the ASST-negative CU group (2.53 +/- 1.27; P = 0.029) and the control group (2.34 +/- 1.38; P = 0.003). CONCLUSION: CU with positive ASST is characterized with higher clinical severity, increased MPV and C-reactive protein.

Circulating endothelial progenitor cells, Th1/Th2/Th17-related cytokines, and endothelial dysfunction in resistant hypertension.

INTRODUCTION: A possible link between chronic vascular inflammation and arterial hypertension is now an object of intensive studies. OBJECTIVE: To compare Th1/Th2/Th17 cells-related cytokines, circulating endothelial progenitor cells (EPC), and endothelial function in subjects with resistant arterial hypertension (RAH) and controlled arterial hypertension (CAH). METHODS: Blood pressure was measured by electronic sphygmomanometer. EPC were identified as CD34+/CD133+/kinase insert domain receptor (KDR)+ cells by flow cytometry. Th1/Th2/Th17 cells-related cytokines were identified using the Human Th1/Th2/Th17 Cytokines MultiAnalyte ELISArray Kit. Endothelium-dependent (FMD) vasodilatation of brachial artery was measured by Doppler ultrasound scanning. RESULTS: RAH group (n = 20) and CAH group (n = 20) and 17 healthy individuals (control group) were recruited. In the RAH group, lower blood levels of EPC number (42.4 +/- 16.7 cells/mL) and EPC% (0.19 +/- 0.08%) were observed than in the CAH group (93.1 +/- 88.7 cells/mL; P = 0.017; 0.27 +/- 0.17; P = 0.036) and control group (68.5 +/- 63.6 cells/mL; P < 0.001; 0.28 +/- 0.17%; P = 0.003), respectively. Plasma transforming growth factor-beta1 levels were significantly higher in the RAH group (1767 +/- 364 pg/mL) than in the CAH group (1292 +/- 349; P < 0.001) and in control group (1203 +/- 419 pg/mL; P < 0.001). In the RAH group, statistically significant negative correlation was observed between systolic blood pressure and EPC% (r = -0.72, P < 0.01). FMD in the RAH group was significantly lower (5.5 +/- 0.8%) than in the CAH group (9.2 +/- 1.4; P < 0.001) and in healthy controls (10.1 +/- 1.1%; P < 0.001). CONCLUSION: RAH is characterized by reduced circulating EPC, substantial endothelial dysfunction, and increased plasma transforming growth factor-beta1 levels.

Eradication of Helicobacter pylori can facilitate immune reconstitution in HIV-1-infected immunological non-responders.

OBJECTIVE: A significant number of HIV-1 patients experience poor immune reconstitution despite long-term viral suppression with highly active antiretroviral therapy (immunological non-responders). The aims of the present study were to determine whether eradication of Helicobacter pylori could facilitate a better immune reconstitution in these patients. METHODS: Forty-nine immunological non-responder HIV-1 patients were evaluated by (13)C-urea breath test (UBT) for the presence of active H. pylori infection. They were all asymptomatic. The UBT was positive in 26 (53%) of them. Eleven patients (group 1) were treated with a combination of omeprazole 20mg bid, amoxicillin 1g bid and clarithromycin 500mg bid for 14 consecutive days. Eight weeks later, successful eradication was proven by a repeat negative UBT in all 11 patients. The remaining 15 (group 2) refused the H. pylori eradication treatment. All 26 patients were followed for 24 months and evaluated for blood CD4 and CD8 cell counts and percentages and for plasma HIV-1 viral load. RESULTS: At the time of H. pylori diagnosis and eradication (baseline), CD4 and CD8 cell counts were similar in both study groups. All 11 H. pylori eradicated patients (group 1) had a significant increase in CD4 cell count starting 3 months and peaking 12-18 months after H. pylori eradication. Thereafter, CD4 levels gradually declined. Nevertheless, 24 months after triple therapy it was significantly higher than prior to H. pylori eradication. Parallel reciprocal changes were observed in CD8 cell counts. There were no significant changes in either CD4 or CD8 cell counts in group 2 patients. None of the patients of group 1 demonstrated virological failure, while four (26.7%) group 2 patients experienced virological failure requiring change of highly active antiretroviral therapy (HAART) regimen. CONCLUSION: Triple therapy for H. pylori eradication is associated with a significant, although possibly transient immune reconstitution in HAART-treated HIV-1 patients with viral suppression without immunological response.

Resistant arterial hypertension is associated with higher blood levels of complement C3 and C-reactive protein.

Arterial hypertension is associated with increased plasma levels of complement C3, C4, and C-reactive protein (CRP). The aim of the study was to compare these laboratory markers in patients with resistant arterial hypertension (RAH) and controlled arterial hypertension (CAH). Patients with RAH (n = 34), those with CAH (n = 34), and 26 normotensive controls were included. White blood cell count, erythrocyte sedimentation rates, and blood levels of complement components C3, C4, and high-sensitivity C-reactive protein (hs-CRP) were compared among the study groups. In the RAH group, serum C3 (183.9+/-47.5 mg/dL) and hs-CRP (6.9+/-5.8 mg/L) were higher than in the CAH group (C3, 123.1+/-42.3 mg/dL; P < .001, hs-CRP, 4.2+/-4.8; P = .021, respectively). Significant positive correlations between systolic blood pressure and C3 (r = 0.6481; P < .001) and hs-CRP (r = 0.3968; P = .02) were observed in the RAH group. RAH is associated with higher blood levels of C3 and CRP.

Eradication of Helicobacter pylori infection equally improves chronic urticaria with positive and negative autologous serum skin test.

BACKGROUND: The aim of the study was to examine effects of Helicobacter pylori eradication on chronic idiopathic urticaria (CU) with and without positive aulogous serum skin test (ASST). METHODS: Seventy-eight patients with CU were checked for the positivity ASST and H. pylori urea (13)C-urea breath test ((13)C-UBT). Twenty-one patients were with both positive ASST and positive (13)C-UBT (group A), and 24 patients were with negative ASST and positive (13)C-UBT (group B). All patients with positive (13)C-UBT received a 14-day, open treatment with amoxicillin 1 g b.i.d., clarithromycin 500 mg b.i.d., and omeprazole 20 mg b.i.d. H. pylori eradication was assessed by a second (13)C-UBT after 8 weeks. In control group, 33 patients with CU were included. The effect of H. pylori eradication on CU was evaluated by urticaria activity score (UAS), measured at study entry and at 8 and 16 weeks. RESULTS: At week 8, baseline UAS reduced from 4.7 +/- 1.1 to 2.4 +/- 1.4 (p = .027) in group A and from 4.3 +/- 1.5 to 2.3 +/- 1.2 (p = .008) in group B, without statistically significant difference between the two groups. In control group and in six patients with H. pylori eradication failure, no changes of UAS were noted. CONCLUSION: Eradication of H. pylori infection by triple therapy significantly and equally reduces UAS in CU patients with positive and negative ASST.

Sensitizations to allergens of TRUE test in 864 consecutive eczema patients in Israel.

The TRUE test is a widespread diagnostic tool for initial patch testing of patients with contact dermatitis (CD). From 2002 to 2005, 864 patients with eczema were patch-tested using TRUE test in one Israeli allergology clinic. 547 (63.3%) patients were female and 317 (36.7%) were male. 346 (40%) patients had > or =1 positive patch test reactions. The most common allergens were nickel sulfate for 114 (13.2%) patients, potassium dichromate 111 (12.8%), fragrance mix 59 (6.8%), cobalt chloride 12 (1.4%), ethylenediamine dihydrochloride 11 (1.3%), epoxy resin 11 (1.3%), balsam of Peru 9 (1.0%), carba mix 7 (0.8%), thiomersal 6 (0.7%), wool alcohol 5 (0.6%), black rubber (PPD) mix 5 (0.6%), neomycin 4 (0.5%); Kathon CG, Colophony and Quaternium 15 - each 2 (0.2%), other allergens - each 1 (0.1%). In male patients, carba mix, black rubber (PPD) mix and epoxy resin sensitivity was more frequent, whereas nickel sulfate, fragrance mix, ethylenediamine dihydrochloride and cobalt chloride sensitivity was significantly more frequent in female patients. Our results are in general agreement with previously published reports, excluding the low sensitivity rates to cobalt, which maybe is missed by TRUE test.

Can worms defend our hearts? Chronic helminthic infections may attenuate the development of cardiovascular diseases.

The established risk factors for atherosclerosis fail to fully explain the extent and severity of coronary artery diseases in 50% of the patients. Thus, the causative agents and processes, which may be involved in the pathogenesis of atherosclerosis, are being sought. Notoriously, atherosclerosis and cardiovascular event rates are much lower in developing countries. Clinically, severe infections by intracellular pathogens are widespread mostly in developing countries with poor sanitation, nutrition and massive worm infections. A link between atherosclerosis and helminth infections has never been examined. Based on the present knowledge of immune and infectious mechanisms related to atherosclerosis, it is proposed that chronic helminthic infections can have a significant bearing on the epidemiology of cardiovascular diseases. How can helminthic infections affect the cardiovascular risk? (1) Helminths evade or suppress host immune responses, by producing anti-inflammatory and other immunomodulatory molecules. (2) Helminths induce chronic Th2 activation, which can modify cytokine profiles and immunological responses to heat shock proteins, Chlamydia pneumoniae and cytomegalovirus. (3) The chronic Th2 profile may modulate monocyte activation and chemotaxis to inflammatory sites (atherosclerotic plaques). (4) Chronic Th2 activation may lead to a cytokine profile that could be beneficial for attenuation of atherosclerosis development (upregulation of IL-4, IL-10 and IL-13 and downregulation of proinflammatory cytokines). (5) Helminthic infections may reduce plasma LDL level not only by affecting the host nutrition, but also via modulation of naturally occurring antibodies to cholesterol. Studies are needed to clarify these suggestions. If the hypothesis that helminthic infections impact atherosclerosis is correct, it should be taken into consideration in atherosclerosis immunomodulation therapy and especially in the design of vaccines and vaccine trials.

Resistant arterial hypertension and hyperlipidemia: atorvastatin, not vitamin C, for blood pressure control.

BACKGROUND: Hypertension is considered resistant if blood pressure cannot be reduced to <140/90 mmHg with an appropriate triple-drug regimen, including an oral diuretic, with all agents administered at maximal dosages. This definition has evolved with the development of new therapies and evidence-based data supporting treatment to lower BP goals. OBJECTIVE: To assess whether vitamin C and atorvastatin improve endothelial function and blood pressure control in subjects with resistant arterial hypertension and dyslipidemia. METHODS: Forty-eight hyperlipidemic subjects with RH (office systolic BP >140 mmHg and/or office diastolic BP >90 mmHg notwithstanding antihypertensive treatment with three medications in maximal doses) were randomized into three groups to receive additional medication for 8 weeks. Group VTC (n = 17)--mean 24 hour SBP 150.6 +/- 5.2 mmHg, DBP 86.1 +/- 3.3 mmHg, low density lipoprotein 158.1 +/- 24.5 mg/dl--received vitamin C 500 mg per day; Group ATR (n = 15)--mean 24 hour SBP 153.1 +/- 4.8 mmHg, DBP 87.1 +/- 6.7 mmHg, LDL 162.6 +/- 13.6 mg/dl--received atorvastatin 20 mg/day; and Group PLA (n = 16)--mean 24 hour SBP 151.1 +/- 7.4 mmHg, DBP 84.8 +/- 5.9 mmHg, LDL 156.7 +/- 26.1 mg/dl--received a placebo. High resolution ultrasound was used to calculate brachial artery flow-mediated dilation, and 24 hour ambulatory BP monitoring was performed at study entry and after 8 weeks. RESULTS: In the ATR group there were significant reductions of SBP (deltaSBP1-2: 13.7 +/- 5.6 mmHg, P 0.001), DBP (deltaDBP1-2: 7.8 +/- 5.7 mmHg, P 0.01), LDL (deltaLDL1-2: 67.7 +/- 28.3 mg/dl, P < 0.001) and improvement of brachial artery FMD (deltaFMD2-1: 4.2 +/- 2.6%). No significant changes in BP, LDL and FMD were observed in the other two groups. CONCLUSIONS: In subjects with RH and dyslipidemia, atorvastatin 20 mg/day compared to vitamin C 500 mg/day may help to achieve better BP control and improve endothelial function in a finite period. A larger trial is needed to assess the drug's efficacy in this population for longer periods.