Sea urchin injuries: a review and clinical approach algorithm.

Sea urchin injuries (SUIs) are among the most common marine injuries; however, there are no guidelines to dictate appropriate workup and treatment. Complications vary significantly depending on the extent of injury, site of injury and elapsed time to medical attention. Timely and appropriate management can prevent long-term morbidity despite the deceptively innocuous appearance of these injuries. We review the English literature on SUIs and offer an algorithm to aid in the management of affected patients. We found that superficially retained spines may trigger a local granulomatous inflammatory response, while spines retained near deep structures may induce sea urchin arthritis, inflammatory tenosynovitis, among other delayed complications. Therefore, we recommend immediate inactivation of pro-inflammatory compounds by hot water soaks at the time of injury, followed by extraction of all spines by a physician. Imaging is a valuable component of risk stratification to determine depth and location of spines, which guides selection of appropriate extraction technique to prevent long-term morbidity.

Clinical Features and Management of "Phlebitis-like Abnormal Reaction" After Cyanoacrylate Closure for the Treatment of Incompetent Saphenous Veins.

BACKGROUND: Cyanoacrylate closure for the treatment of incompetent saphenous veins does not cause thermal damage and demonstrates satisfactory outcomes with rapid recovery. However, the characteristics of phlebitis-like abnormal reaction (PLAR), the most common adverse event after cyanoacrylate closure, have not been clarified. Moreover, it differs from typical phlebitis after thermal ablation. The objective of our study is to investigate the clinical features of PLAR after cyanoacrylate closure and to report its management. METHODS: A total of 160 patients with 271 incompetent saphenous veins (great saphenous veins, 201; small saphenous veins, 70) underwent cyanoacrylate closure with the VenaSeal™ system. We defined PLAR as any unusual skin condition that develops suddenly, such as erythema, itching, swelling, and pain/tenderness, over the treated veins several days after cyanoacrylate closure. Oral antihistamines and intravenous dexamethasone were administered to manage PLAR. RESULTS: Of the 271 treated veins, 69 experienced PLAR (25.4%). The mean time of occurrence was 13.6 ± 4.6 days after treatment. The rate of occurrence of erythema, itching, swelling, and pain/tenderness were 92.2%, 91.2%, 66.2%, and 48.5%, respectively. The occurrence of PLAR was significantly higher for great saphenous veins than for small saphenous veins (P < 0.001). Occurrences were more frequent in cases with a suprafascial great saphenous vein of length >10 cm than in cases with a subfascial great saphenous vein (P = 0.001). The proportion of patients who reported swelling decreased by more than half after the administration of oral antihistamine. The pain score on the 10th day also decreased significantly after the administration of antihistamine (P = 0.006). CONCLUSIONS: PLAR must be distinguished from classic phlebitis. We believe that PLAR is a type IV hypersensitivity reaction due to a foreign body, and in our experience, antihistamines or steroids are effective for the prevention and management of PLAR.

Nickel-associated delayed multiple white matter lesions after stent-assisted coil embolization of intracranial unruptured aneurysm.

Metal-induced encephalopathy after stent-assisted coil embolization is extremely rare. The present report describes two patients who presented with symptomatic intracranial parenchymal edematous lesions after stent-assisted coil embolization. A 64-year-old woman underwent stent-assisted coil embolization for a left internal carotid artery aneurysm; 21 days after the procedure she presented with right hand weakness and MRI revealed multifocal white matter lesions. Another woman aged 52 years underwent stent-assisted coil embolization for right vertebral artery aneurysm; 18 days after the procedure she presented with left-sided sensory disturbance and MRI demonstrated multiple white matter lesions. Treatment in both cases resulted in improvement of these lesions after steroid pulse therapy, and the patients had no associated morbidity 4 months after the procedures. Clinicians should monitor for neurologic symptoms and postoperative delayed radiologic parenchymal edematous changes associated with the metal allergic reaction after nitinol stent-assisted coil embolization.

Murine Lymphocyte Labeling by 64Cu-Antibody Receptor Targeting for In Vivo Cell Trafficking by PET/CT.

This protocol illustrates the production of 64Cu and the chelator conjugation/radiolabeling of a monoclonal antibody (mAb) followed by murine lymphocyte cell culture and 64Cu-antibody receptor targeting of the cells. In vitro evaluation of the radiolabel and non-invasive in vivo cell tracking in an animal model of an airway delayed-type hypersensitivity reaction (DTHR) by PET/CT are described. In detail, the conjugation of a mAb with the chelator 1,4,7,10-tetraazacyclododecane-1,4,7,10-tetraacetic acid (DOTA) is shown. Following the production of radioactive 64Cu, radiolabeling of the DOTA-conjugated mAb is described. Next, the expansion of chicken ovalbumin (cOVA)-specific CD4+ interferon (IFN)-γ-producing T helper cells (cOVA-TH1) and the subsequent radiolabeling of the cOVA-TH1 cells are depicted. Various in vitro techniques are presented to evaluate the effects of 64Cu-radiolabeling on the cells, such as the determination of cell viability by trypan blue exclusion, the staining for apoptosis with Annexin V for flow cytometry, and the assessment of functionality by IFN-γ enzyme-linked immunosorbent assay (ELISA). Furthermore, the determination of the radioactive uptake into the cells and the labeling stability are described in detail. This protocol further describes how to perform cell tracking studies in an animal model for an airway DTHR and, therefore, the induction of cOVA-induced acute airway DHTR in BALB/c mice is included. Finally, a robust PET/CT workflow including image acquisition, reconstruction, and analysis is presented. The 64Cu-antibody receptor targeting approach with subsequent receptor internalization provides high specificity and stability, reduced cellular toxicity, and low efflux rates compared to common PET-tracers for cell labeling, e.g.64Cu-pyruvaldehyde bis(N4-methylthiosemicarbazone) (64Cu-PTSM). Finally, our approach enables non-invasive in vivo cell tracking by PET/CT with an optimal signal-to-background ratio for 48 h. This experimental approach can be transferred to different animal models and cell types with membrane-bound receptors that are internalized.

Orbital inflammation secondary to a delayed hypersensitivity reaction to sub-Tenon's hyaluronidase.

We report a rare case of a delayed orbital inflammation with raised intraocular pressure as a result of hyluronidase allergy following sub-Tenon's anaesthesia. Here, we have shown evidence to prove the orbital inflammation to be an allergic response to hyluronidase with a skin patch test. This is the first case to our knowledge of a delayed hypersensitivity reaction to sub-Tenon's hyluronidase comprising of an initial exposure to hyluronidase in the fellow eye with no subsequent allergic response, but with a subsequent delayed reaction to hyluronidase during a second eye cataract surgery. This case demonstrates hyaluronidase allergy should be considered as a differential diagnosis among patients presenting with acute post-operative orbital inflammation, even if there is a history of previous exposure to hyaluronidase in the fellow eye with no subsequent allergic response.

[Pathological findings in tissue surrounding revised metal/metal articulations]. / Pathologische Veränderungen im umgebenden Gewebe von revidierten Metall-Metall-Gleitpaarungen.

INTRODUCTION: The aim of the current study was to elucidate the incidence of allergic reactions to metal/metal articulations in revised total hip arthroplasties. MATERIALS AND METHODS: Between 1 January 1997 and 31 January 2002 a consecutive series of tissue samples from 13 revised total hip arthroplasties with metal/metal articulations were histopathologically examined for signs of delayed type hypersensitivity (DTH). Mean age at the time of revision of the eight women and five men was 58.7 years. The prostheses were revised after a mean follow-up of 45 months. Indications for revision were progressive osteolysis of the proximal femur in 12 cases and instability in one case. All patients were clinically and radiologically evaluated after a mean follow-up of 52 months (min. 22, max. 74) after revision. RESULTS: No signs of infection were found in either histopathological or microbiological examinations. In ten cases, perivascular lymphocytic infiltrates could be found as a sign of DTH. After revision and changing of the articulation all osteolyses healed. CONCLUSION: In 10/13 cases (76.9%) signs of DTH could be detected. The fact that all osteolyses healed after changing the articulation may give a strong hint that there is an immunological contribution to this radiological changes. Metal/metal articulations cannot be recommended as the optimum implant for young patients, as the number of patients with allergic reactions to nickel, chrome or cobalt is increasing continuously.

Imaging of delayed-type hypersensitivity reaction by PET and 18F-galacto-RGD.

UNLABELLED: Radiolabeled cyclic peptides containing the amino acid sequence arginine-glycine-aspartate (RGD peptides) have successfully been used to image the expression of the alpha(v)beta(3) integrin in malignant tumors. However, the alpha(v)beta(3) integrin also plays an important role in angiogenesis induced by chronic inflammatory processes. Therefore, the aim of this study was to evaluate whether radiolabeled RGD peptides may also be used to assess alpha(v)beta(3) expression in inflammatory diseases. We studied a hapten-induced delayed-type hypersensitivity reaction (DTHR) as a model for inflammatory processes, since DTHRs are involved in many human autoimmune disorders. METHODS: The abdominal skin of mice was sensitized by application of 2,4,6-trinitrochlorobenzene (TNCB). One week later, a DTHR was elicited by challenging the right ear with TNCB. Application of TNCB was then repeated every 48 h to induce chronic skin inflammation. Small-animal PET and autoradiography with the alpha(v)beta(3) ligands (18)F-galacto-RGD and (125)I-gluco-RGD were performed at various times after TNCB application. The time course of tracer uptake by the treated ears was compared with histologic skin changes. RESULTS: The first challenge with TNCB caused, within 12 h, an acute inflammatory response with dense dermal infiltrates of polymorphonuclear leukocytes and lymphocytes. However, autoradiography revealed no significant increase in (125)I-gluco-RGD uptake at that time (mean uptake ratio for treated ear to untreated ear, 1.02 +/- 0.1 [SD]). Further challenges with TNCB resulted in chronic skin inflammation with markedly increased small-vessel density in the ear tissue. This was paralleled by a continuous increase in uptake of (125)I-gluco-RGD. After 13 challenges, the uptake ratio had increased to 2.30 +/- 0.27 (P < 0.005 compared with baseline). Enhanced uptake of radiolabeled RGD peptides in chronic inflammation was also demonstrated noninvasively by PET with (18)F-galacto-RGD. Pretreatment of the mice with nonradiolabeled cyclic peptide c(RGDfV) almost completely blocked uptake of (18)F-galacto-RGD by the challenged ear, thus confirming the specificity of tracer uptake. CONCLUSION: Radiolabeled RGD peptides allow a noninvasive assessment of alpha(v)beta(3) expression in inflammatory processes. PET with (18)F-galacto-RGD might become a powerful tool to distinguish between the acute and chronic phases of T cell-mediated immune responses and may represent a new biomarker for disease activity in autoimmune disorders.

Subcutaneous nodules at the injection site of low-molecular-weight heparin: a mimic of metastatic disease at CT.

PURPOSE: To describe the appearance and prevalence of subcutaneous nodules in the anterior abdominal wall seen at CT in cancer patients receiving subcutaneous injections of low-molecular-weight heparin (LMWH). METHODS: CT examinations were reviewed in 426 patients receiving subcutaneous abdominal wall injections of LMWH for the presence of nodules. Nodules were evaluated for contour, maximal diameter, CT attenuation, and presence of hazy changes or air in the surrounding fat. RESULTS: Fourteen (3%) of the 426 patients had nodules attributable to subcutaneous injections of LMWH. Findings included poorly defined borders (100%), adjacent hazy soft tissue changes (100%), adjacent air (57%), and a mean CT attenuation of -4.4 HU (range: -50-40 HU). Three (0.7%) of 426 patients had nodules caused by metastatic disease. One (33%) nodule had poorly defined borders, two (67%) had surrounding hazy changes, one (33%) had air in adjacent tissue, and there was a mean CT attenuation of 44 HU (range: 14-140 HU). One (0.2%) patient had a subcutaneous nodule of uncertain etiology. CONCLUSION: Patients receiving subcutaneous injections of LMWH may develop nodules at the injection sites. Such nodules can resemble metastatic tumor deposits at CT, and careful correlation with clinical history and growth trends of metastatic deposits elsewhere in the patient is needed to avoid misdiagnosis.

Two-dimensional blood flow determinations in allergic reactions using laser Doppler scanning.

The new technique of laser Doppler scanning (LDS) provides a 2-dimensional pattern of cutaneous microcirculation, which offers a visual image and can quantify the intensity and expansion of perfusion. With the help of this technique, we examined the microcirculatory pattern of Type IV reactions to recall antigens, which were applied using a test stamp (Multitest Merieux). The measurements were performed before application of the test stamp as well as 10 min, 24, 48 and 72 h afterwards. The inflammatory hyperemia was evaluated using LDS and unidimensional laser Doppler fluxmetry. The diameter of the inflammatory infiltrate was quantified by means of palpation, the thickness by means of high-resolution 20 MHz sonography. The clinically visible erythema was measured planimetrically. An unspecific hyperemia resulting from the trauma of the stamp revealed no evident infiltrate under sonography 10 min after the test application. Depending of the individual reaction, the mean flux and the expansion of the hyperemia were at their peak after 48 h. The flux values were at a maximum in the center of the inflammatory reaction and dropped continuously toward the periphery. The area of the hyperemia seen in the LDS image was significantly larger than the expansion of the erythema measured planimetrically, but there was a significant correlation. The perfusion correlated significantly with the infiltration diameter (24 h, 48 h, 72 h) and the infiltration thickness 48 h after testing. All in all, it was possible to measure directly and without touching the skin and to quantify a subclinical pattern of skin perfusion as a response to and inflammatory reaction on a 2-dimensional display.

Sonographic quantification of the type IV reaction after intradermal application of recall antigens.

20-MHz B-scan high-resolution sonography permits non-invasive, two-dimensional visualisation of micromorphological structures in vivo, and allows precise measurement of the depth and extent of inflammatory skin lesions. In 50 patients, the reactions following intradermal application of 8 recall antigens to the volar forearm were evaluated clinically and sonographically at various times (0, 24, 48, 72 h). In 30 patients, one of the inflammatory papules was excised after 48 h for complete histological work-up (serial sections) and subsequent comparison with the sonographic image. Infiltrates were characterised in the ultrasound scans by the almost regular occurrence of convexity of the skin surface, by a loosened structure (loss of echogenicity) of the corium and by protrusion of the corium into the subcutaneous fatty tissue. It was also possible to follow the dynamics of the type IV reaction with the measurement of echogenicity (densitometry). High-frequency ultrasound is an objective, exact and very sensitive tool for the measurement of type IV reactions after intradermal application of recall antigens and therefore superior to clinical evaluation. The B-scan was superior to the A-scan. However, for routine evaluation of tuberculin-like reactions, sonography is too time-consuming. Our results suggest that densitometry provides no additional or necessary information compared to sonometry.

Requirements for flare reactions of joint inflammation induced in mice by cloned MT4+, Lyt-2- T cells.

Joint inflammation was induced in C57B1/6 mice by injection of cloned MT4+, Lyt-2- T cells specific for the antigen methylated bovine serum albumin (mBSA), together with mBSA. In this model, after waning of the inflammation, flare reactions can be induced by a rechallenge with the specific antigen. Herein we show that such flare reactions can still be induced several weeks after waning of the joint inflammation, as was demonstrated both in normal C57B1/6 mice and in athymic C57B1 nude mice. The results in the latter group indicate that T cells of the recipient mice are not necessary for the elicitation of flare reactions. On histologic examination, the inflammatory infiltrates in the knee joints of the nude mice appeared to be mainly granulocytic. The cloned T cells persisted and remained functionally reactive in the knee joint for at least 2 weeks in the absence of the antigen, and thus, in the absence of inflammation. In view of the similarities between induced joint inflammation in mice and rheumatoid arthritis in humans, these data may be relevant to our understanding of the processes involved in the latter disease.

Application of a radiometric ear assay for studies of adjuvant arthritis in rats.

A radioisotopic method, originally developed for measuring the cellular response in delayed hypersensitivity lesions in mice, has been evaluated in adjuvant arthritic rats. Focal accumulation of 5-iodo-2'-deoxyuridine-125I (125IUdR) at a site of antigen challenge (left pinna) was measured and expressed as increased radioactivity in the challenged (left) over the unchallenged (right) ear (L/R ear ratio). Immunologic specificity of the assay was established with anti-lymphocyte globulin (ALG)-treated arthritic rats. ALG significantly inhibited the 125IUdR L/R ear ratio; normal rabbit globulin had no effect on this parameter. A significant negative correlation was observed between the 125IUdR ear ratios and subjective arthritic scores in established adjuvant disease. Certain characteristics of the 125IUdR radiometric ear assay in rats were established in several types of experiments: disappearance of the isotope from blood, whole body irradiation studies in turpentine-injected rats, and cyclophosphamide pretreatment in a sheep erythrocyte antigenic system. The results of this study support the utility of the 125IUdR ear assay to quantify cellular accumulation at a site of antigen challenge in adjuvant arthritic rats and possibly other antigenic systems in this species.