[Lysis of an extensive thrombus in the internal carotid artery using a glycoprotein IIb/IIIa receptor antagonist]. / Lyse eines ausgedehnten Thrombus in der Arteria carotis interna durch einen Glykoprotein IIb/IIIa-Rezeptorantagonisten.

HISTORY: A 55-year-old man was admitted with acute right-sided arm and leg paralysis and motor aphasia, which were regressing at time of admission. He was known to have had several episodes of abnormal motor function in the right arm resulting from transitory cerebral ischaemic attacks. He was a heavy smoker. INVESTIGATIONS: Cranial computed tomography (CCT) excluded acute bleeding and there was no evidence of a stroke. Duplex sonography showed a filiform stenosis at the origin of the left internal carotid artery (ICA) with an echo-poor structure in the distal lumen. Subsequent angiography demonstrated an inoperable thrombus adherent to the filiform left ICA stenosis and extending to the base of the skull. DIAGNOSIS, TREATMENT AND COURSE: The neurological symptoms regressed over 24 hours, confirming the diagnosis of prolonged ischaemic neurological deficit. CCT having excluded bleeding, but significant left ICA stenosis by a thrombus having been demonstrated, treatment with acetyl salicylic acid (aspirin) and heparin was initiated. After the described angiographic confirmation of a thrombus adherent to the filiform stenosis, treatment with Tirofiban, a glycoprotein (GP) IIb/IIIa receptor antagonist, was begun and the thrombus completely dissolved. The filiform ICA stenosis was then treated surgically. CONCLUSION: This case demonstrates complete lysis of a long thrombus in the ICA by Tirofiban, making a primarily inoperable stenosis amenable to surgical intervention. It is not yet clear whether administration of GP IIa/IIIb receptor antagonists provides a therapeutic option in the treatment of intracranial arterial thromboses.

[Yersinia arthritis. Long-term follow up]. / Yersinien-Arthritis. Langzeitbeobachtungen.

Twenty-two patients were followed for a mean of 10.7 years after acute Yersinia arthritis. Their clinical course, agglutinating antibodies, and laboratory parameters of inflammation were analyzed. In 73% of cases HLA-B27 was positive. The acute disease lasted from 1 month to 1 year. One male patient showed a bilateral synostosis of sacroiliac joints at the acute phase of the disease. He developed the clinical characteristics of severe ankylosing spondylitis. Another two patients with HLA-B27 had radiologically inflammatory changes of sacroiliac joints or symphysis without clinical findings. Agglutinating antibodies against dead Yersinia bacilli were negative in all patients. No laboratory signs of inflammation were present. The long-term prognosis of Yersinia arthritis is benign.

Long term prognosis in yersinia arthritis: clinical and serological findings.

Twenty two patients were followed up for a mean of 10.7 years after acute yersinia arthritis. Their clinical course, agglutination antibodies, antibodies against plasmid coded yersinia proteins, and laboratory parameters of inflammation were analysed. The clinical findings were unremarkable. Serum agglutinating antibodies against Yersinia enterocolitica were not found in any patient. Ten patients had no antibodies against plasmid coded bacterial proteins. Five patients showed IgG antibodies, one patient had an IgA and IgG result of questionable significance, and six patients had IgA and IgG antibodies in the immunoblot reaction. No evidence of systemic inflammation was found. The persistence of IgA or IgG antibodies, or both, did not have a discernible influence on the clinical course. The development of erosive changes in the sacroiliac joints occurred independently of yersinia infection.

[Atrial lipoma as a cause of tachycardiac arrhythmia]. / Vorhoflipom als Ursache tachykarder Herzrhythmusstörungen.

A 41-year-old man had paroxysmal tachycardic arrhythmias. Computed tomography revealed a right atrial lipoma, 7 cm in diameter. After the tumour had been removed (with histological confirmation of the diagnosis) the arrhythmia ceased. Such tumour must be considered in the differential diagnosis of tachycardic arrhythmias of undetermined origin.

[Intracellular gold content of circulating blood cells using various gold compounds]. / Intrazellulärer Goldgehalt in zirkulierenden Blutzellen unter unterschiedlichen Goldverbindungen.

Evidence on the action mechanisms of gold salts in the treatment of rheumatoid arthritis is still inconclusive. The intracellular localization of the place of action is likely. Therefore not only the serum gold levels but also the intracellular concentration of gold are of special interest. We measured the gold concentration in the serum and in the blood cells after in vitro application of aurothiomalate (Tauredon), gold keratinate (Auro-Detoxin) and triethylphosphine-gold (Ridaura) and in blood samples of patients undergoing these gold salts treatments. Cell-bound concentrations were found to vary extensively as a function of the gold compound used. While no or very little gold was present intracellularly after administration of the 2 parenteral drugs, up to 40% of the circulating gold was found to bind to the cells after administration of the triethylphosphine compound for gastro-intestinal absorption. The red cell concentration was more or less the same as that in the extracellular compartment. Gold apparently accumulated in the white cells, because the cell-bound concentration relative to unit volume was up to 20 times higher than the plasma level. The method used did not offer any information on the actual binding site of gold in white cells, i.e. cytoplasm versus nucleus versus cell membrane.

[Successful conservative treatment of bronchial carcinoid with Cushing's syndrome due to ectopic ACTH production]. / Erfolgreiche konservative Behandlung eines Bronchialkarzinoids mit Cushing-Syndrom infolge ektoper ACTH-Produktion.

In a 53-year-old female patient with typical clinical Cushing's syndrome increased blood sugar levels, hypokalaemia, increased non-dexamethasone suppressable plasma cortisol levels and increased ACTH values in serum were observed. CAT scanning revealed bilateral adrenocortical hyperplasia. The endocrine anterior pituitary function was normal. Radiographically and bronchoscopically a rightsided parahilar tumour was found. Histology showed an atypical metastatic bronchial carcinoid with ectopic ACTH production. Conservative treatment with metyrapone suppressed the Cushing syndrome. The ACTH producing tumour responded to combined chemo- and radiotherapy. The patient is symptom free two years after onset of treatment.

[Hyperostosis of the sterno-clavicular joint - an enthesopathy?]. / Hyperostose der Sternoklavikulargelenke - eine Enthesopathie?

Erosion of the insertions of tendons and ligaments in bone (i.e. of the enthesis) due to chronic aseptic inflammation causes reparative ossification. With regard to our clinical and radiological findings in ten patients hyperostosis of the sterno-clavicular joint seems to be the late stage of such an enthesopathy. Pain and swelling of the soft tissues and an elevated erythrocyte sedimentation rate are characteristics of this seronegative rheumatic disease. For visualizing the extraarticular changes in the sterno-costo-clavicular region tomography is necessary. Early diagnosis and consequent antiphlogistic therapy should remit pain and help avoid hyperostosis.

[Protein binding of gold in serum of patients treated with different gold preparations]. / Eiweissbindung von Gold im Serum unter verschiedenen Goldpräparaten.

Binding of gold to serum proteins of patients treated with Na-aurothiomalate (AM), gold keratinate (GK) and triethylphosphine gold (PG) was compared. In addition the pattern of distribution of gold in serum of healthy donors after in vitro incubation with these compounds and with tetrachlorogoldacid (GC) was studied. Serum specimens were fractionated by gel filtration (Sephadex G 200), gold was measured by atomic absorption spectroscopy, concentration of protein was calculated by extinction at 280 nm. After incubation with AM, PG and GC in vitro gold binds to serumproteins rapidly and completely (concentration of gold with AM and GC about 5 mg/l, with PG about 1 mg/1). The distribution among the protein fractions is different, however. With AM and GC 94% of gold is bound to albumin and only 6% to globulin. The corresponding figures with PG are 70% respectively 30%. With GK gold binds not completely to serum proteins in vitro. Even after 24 hours incubation about 7% are unbound. The affinity to globulin is high with GK (20%). On principle the pattern of distribution of gold is the same in vivo. The concentration of gold in the serum was almost the same as during the in vitro experiments. No unbound gold was found with GK. The affinity to globulin increases from AM to GK and especially to PG. The reason for these typical patterns are at least in part different metabolic pathways of the gold compounds. These findings may explain some differences of efficacy of certain goldcompounds.

Oral gold therapy with auranofin (SK&F 39162). A multicenter open study in patients with rheumatoid arthritis.

One hundred and fifty patients with rheumatoid arthritis received 6 mg of auranofin daily for 2-24 months. Thirty patients were withdrawn from the study, and 82 patients were observed for 12 months. Statistical evaluation was available for 74 patients at weeks 24, 38, and 48, respectively. The major side effects observed were diarrhea, rash, and alopecia. Significant improvement was noted in the articular index, ESR, pain, and morning stiffness.

Distribution of gold in serum erythrocytes and white blood cells after in vitro incubation and during chrysotherapy with different gold compounds.

We examined the binding of gold to serum proteins and the gold level in serum and in blood cells both after incubation in vitro and under longterm treatment with 3 gold compounds. Gold was measured by atomic absorption spectrophotometry, a serum fractionated by gel chromatography; blood cells were separated by gradient centrifugation, and intracellular gold was measured after pressure decomposition and MIBK-extraction. Aurothiomalate (GSTM), gold keratinate (GK), and auranofin (AF) were used. AF showed the highest binding to globulins in in vitro and in vivo. With GSTM and GK there were no measurable amounts of gold in the red cell lysate or erythrocyte membranes whereas with AF 40% of gold was localized within erythrocytes. The amount of gold in granulocytes and mononuclear cells after incubation with AF is considerably higher than with GK and GSTM.

[Clinical trial in couples of effectiveness and side-effects of gold and D-penicillamine in long term treatment of rheumatoid arthritis (author's transl)]. / Untersuchung von Wirksamkeit und Nebenwirkungen der Medikamente Gold und D-Penicillamin bei der Basisbehandlung der chronischen Polyarthritis im paarweisen Vergleich.

A prospective clinical trial in couples was done to compare effectiveness and toxicity of gold and D-penicillamine (D-Pen.) in treatment of rheumatoid arthritis (r.A.). Respecting defined criteria 70 patients were put to couples according to a random list and were treated with gold or D-Pen. alternatively. Physical and laboratory indices of inflammatory activity were checked every 3 months, X-rays every 12 months. Dropouts (side effects, missing compliance, uneffectiveness) were replaced by the nextcoming fitting patient. Thirty-two of 147 totally recruited patients stopped treatment because of side effects, three because of unsatisfying efficiency. Forty-two patients shuned the necessary controls. The clinical course was better in 16 couples with gold, only in sex couples with D-Pen. Thirteen pairs showed no difference in this respect (p = 0.05). Looking to the laboratory parameters separately D-Pen. tends to be superior (p < 0.05), radiografic deterioration seems to be more seldom with gold (< 0.05). Side effects occur with both drugs in comparable frequency (15/44 with D-Pen., 17/52 with gold), but the complications with D-Pen. are more serious. Altogether this trial shows gold superior to D-Pen. in the long-term treatment of r.A.

[Pharmacokinetics of gold after administration of aurokeratinate (author's transl)]. / Das pharmakokinetische Verhalten von Gold nach Gabe von Aurokeratinat.

Aurokeratinate (Auro-Detoxin) was administered intramuscularly to patients with chronic rheumatoid arthritis, using two different dosage schedules and measuring serum gold concentration. (1) Using slowly rising doses (as generally practised) the gold level gradually rose to 3.2 microgram/ml after four weeks (before the ninth injection), without reaching cumulation equilibrium. Elimination from serum occurred during this phase, with a half-life of 3-5 days. When treatment was continued at about 25 mg gold twice weekly, the cumulation equilibrium was reached with a minimal value at 3.5 microgram/ml and a maximal one of 6 microgram/ml, elimination half-life then being increased to nine days. During the subsequent maintenance treatment with 65 mg gold once a month the serum-gold concentration fell to about 1 microgram/ml, maximal values being about 6 microgram/ml, with an elimination half-life of 11 days. (2) With a constant dose of about 25 mg gold twice weekly, cumulation equilibrium was reached after two weeks (3.4 microgram/ml before the fifth injection), while on 50 mg gold every 14 days as maintenance dose the serum concentration was between 2 microgram/ml minimally and 6 microgram/ml maximally. At the modified dosage the drug was well tolerated.

[Yersinia arthritis (author's transl)]. / Yersinia-arthritis.

Clinical picture and differential diagnosis of Yersinia arthritis are shown by means of three own observations. It is an acute oligoarthritis affecting especially knee- and ankle-joints. The involved joints are very painful, swollen and warm. There may be a history of enteritis or suspicion of acute appendicitis because of lower abdominal pain, but this is not obligatory. The laboratory parameters of inflammation (ESR, C-reactive protein, white blood count, serumproteinelectrophoresis) are changed significantly. Diagnosis is made by serum agglutination reaction (Widal-reaction) against ceesurface antigens (O-antigens) of Yersinia enterocolitica. Almost only people with the HL-A antigen B27 tend to get arthritis during Yersinia infection. The differential diagnosis has to consider reactive arthritis during Salmonella or Shigella infections, acute sarcoidosis, Reiter's disease and rheumatoid arthritis.

B cell activity in rat bone marrow and spleen during primary and secondary response: dependence on strength of antigen.

B cell activity was studied in the spleen and the bone marrow of inbred rats after applying xenogeneic erythrocytes of different antigenic strength (mouse or sheep). The hemolytic plaque technique of Cunningham was used. In contrast to the studies of other authors with other species, these experiments showed that in the rat the kinetics of IgM and IgG responses in bone marrow and spleen are principally similar during a primary as well as during a secondary reaction, varying only with the strength of the antigen.