Endotracheal tuberculous stenosis: ventilation rescue and bronchography guided stenting.

We present the case of a 16-year-old female patient who presented with dyspnoea, cough and noisy breathing that progressed further in hospital with the development of stridor and severe respiratory compromise requiring mechanical ventilatory support. Investigations were consistent with a diagnosis of endotracheal tuberculosis with tracheal and bronchial stenosis. Despite adequate anti-tuberculous therapy and ventilation the patient had high airway pressures, low tidal volumes and hypercapnia, which prevented weaning from mechanical ventilation. Balloon dilatation and stenting of the 4.5cm long, 2.3mm diameter stenotic tracheal segment was performed under radiological guidance. The patient was weaned successfully from the ventilator post-procedure. This report illustrates the successful management of an uncommon presentation of a common disease with modern endoscopic therapy.

Multifocal idiopathic fibrosclerosis mimicking tuberculosis of the abdomen.

We present a 13 year old girl from Assam who had been treated as abdominal tuberculosis for 2 years due to the presence of refractory lymphocyte-predominant ascites and multiple small bowel strictures associated with significant anorexia and weight loss. On evaluation she was found to have retroperitoneal fibrosis with hydroureteronephrosis, mediastinal fibrosis and a retro-orbital pseudotumour. Based on these findings the diagnosis of Multifocal Idiopathic Fibrosclerosis (MIFS) was made. Ascites and multiple bowel strictures have been only rarely been described in association with MIFS. The other unique features in this patient were the early age of presentation, the presence of mediastinal fibrosis in association with retroperitoneal fibrosis, extensive soft tissue fibrosis of the neck, axillae and the presence of trismus. In a country like ours where Tuberculosis is commonplace, one would not think twice about treating such a case with antituberculous therapy. However, with a constellation of findings suggestive of a diffuse fibrotic process, MIFS should be an important consideration.

Acenocoumarol and phenytoin toxicity in the presence of CYP2C9 mutation.

This case report describes a rare interaction between therapeutic doses of phenytoin and acenocoumarol resulting in both acute phenytoin toxicity and increased international normalized ratio (INR). Interactions between these drugs are due to the pharmacokinetics and the common metabolising pathway by hepatic cytochrome P450 isoenzyme-CYP2C9. Our patient was detected to be homozygous for CYP2C9*3 by PCR-RFLP analysis resulting in markedly decreased metabolism of both the drugs. Given that these two drugs are often given concomitantly in the medical out patient department, and that CYP2C9 polymorphisms are not uncommon, clinicians should be aware of this interaction and suspect this in patients with toxicity to these drugs.

The urticarias. Current concepts in pathogenesis and treatment.

Urticaria is a very common disease which is often associated with angioedema. Release of histamine and perhaps other mediators from the cutaneous mast cells is believed to be the likeliest cause for the development of these wheals in most instances, but there may be both non-immunological as well as immunological inputs into this final common pathway. The former include trauma, cholinergic mechanisms and non-immunological histamine release by drugs. Immune mechanisms most commonly are of the IgE-mediated type, but occasionally the activation of complement or other mediators of hypersensitivity may be involved. Drug and food allergy are among the most common causes of acute urticaria, but there are numerous other possibilities which mandate a thorough general medical history and physical examination (including ruling out infection, connective tissue disease and neoplasms). In cases of chronic urticaria, when the lesions have persisted for longer than about 2 months, no cause for the disease is discernable in most instances. However, in these cases, as well as in acute urticaria, symptomatic treatment generally can provide substantial symptom relief, with emphasis on the astute use of various types of antihistamines.

Aspirin-sensitive asthma.

Aspirin intolerance is particularly common in asthmatic patients who additionally have chronic rhinitis and/or nasal polyps. These individuals differ in several respects from patients who experience urticaria and/or angioedema after aspirin administration, and differing mechanisms may be involved. Data regarding the latter are indirect and incomplete, but suggest that ASA-sensitive asthma is most likely to be related in some manner to the capacity of ASA to inhibit cyclooxygenases, enhanced lipoxygenase metabolism perhaps playing a crucial role. Current research employing ASA "desensitization" may help to elucidate these enigmas.

Ultrastructural and functional studies of cilia from patients with asthma, aspirin intolerance, and nasal polyps.

"Triad" asthmatics often have sinus disease, nasal polyps, and obstructive airways disease. This presentation is reminiscent of the symptoms of persons afflicted with various forms of ciliary dyskinesia. Therefore, we examined tissues from seven "triad" asthmatic patients for ciliary structural or functional abnormalities. Transmission and scanning electron microscopy revealed no specific abnormalities. Cultures of nasal epithelia were maintained for up to 20 weeks. They showed normal ciliary activity which was not influenced by perfusing the tissue with medium containing aspirin. In contrast, control tissue from a patient with situs inversus and sinusitis showed the expected structural and functional ciliary abnormalities. In culture, the ciliary function of tissue from this patient could be partly restored by perfusion with ATP or ATPase.

Peripheral CD4+/CD8+ T-lymphocyte counts estimated by an immunocapture method in the normal healthy south Indian adults and HIV seropositive individuals.

BACKGROUND: Flow cytometry is the standard method for the estimation of CD4/CD8 counts, but the high initial investment for this instrument and costly reagents make it unaffordable to most of the centers in a developing country like India. OBJECTIVES: To evaluate the feasibility of an alternate system for the estimation of CD4 and CD8 counts in normal south Indian adults and validate the usefulness of this assay to monitor the counts in HIV seropositive individuals. STUDY DESIGN: Forty-six normal healthy adults and 68 HIV seropositive individuals both belonging to south Indian linguistic groups were enrolled in this cross-sectional study. The HIV seropositive individuals included 54 HIV-1, 9 HIV-2 and 5 HIV 1&2 infected individuals serologically confirmed by one of the commercial Immunoblot kits. The Capcellia CD4/CD8 whole blood assay, an immuno-capture ELISA based kit from Sanofi DIAGNOSTICS Pasteur, (France) was used with a few modifications in the procedure to measure the CD4 and CD8 counts. RESULTS: The mean CD4 cell counts were 1048 (central 95 centile only), 746 and 424 for the normal healthy adults, asymptomatic HIV seropositives and symptomatic HIV patients, respectively, and the mean CD8 counts were 595, 889 and 732, respectively. Statistically significant differences were observed in the CD4 cell counts between HIV seronegative healthy adults and asymptomatic (P < 0.001) as well as asymptomatic and symptomatic (P < 0.05) HIV infected individuals. The mean CD4 counts of asymptomatic HIV-2 infected individuals was significantly higher than the counts of asymptomatic HIV-1 infected individuals (P < 0.05). CONCLUSIONS: This is an user friendly test and can be an alternate to flow cytometry for the estimation of peripheral T-lymphocyte subsets in developing countries. The assay system has certain limitations inherent to ELISA techniques.

Determination of total IgE by ELISA in tubes and plates compared with PRIST.

IgE was measured by ELISA in tubes and in microtiter plates, the results being compared with PRIST data. The recommended readings of the tube contents in a spectrophotometer (SPM) were compared with results using a multi-channel photometer (MCP). Geometric mean values (International Units) and standard deviations of 44 normal sera examined by the 3 different methods were: PRIST 16.2 +/- 4.0; SPM 15.6 +/- 4.9 and MCP 18.4 +/- 4.4. Correlation coefficients were: PRIST-SPM r = 0.98; PRIST-MCP r = 0.98; and SPM-MCP r = 0.97. Intra- and inter-assay coefficients of variation were smaller for MCP than for SPM. In addition, reading in microtiter plates was much faster, while having little effect on sensitivity.

Effect of ammonia on nasal resistance in atopic and nonatopic subjects.

Nasal airway resistance (NAR) was assessed from the slope of pressure-glow curves obtained during normal nasal breathing. Volunteers were classified as atopic or nonatopic according to strict critera. 100 ppm NH3 was introduced into each nostril for periods ranging from 5 to 30 seconds with frequent NAR monitoring. A progressive increase in NAR responses was obtained with incremental NH3 exposure, but no significant difference was noted between the mean response of atopic and nonatopic subjects. Control exposures to compressed air under the same pressure generally produced only a small change in NAR, while aerosolized buffered saline increased NAR more than compressed air. The nasal response to NH3 was effectively inhibited by intranasal atropine administration but not by chlorpheniramine. The nasal response to NH3 was effectively inhibited by intranasal atropine administration but not by chlorpheniramine. The described procedure provides a safe and simple method for studying semiquantitatively the short-term effects of inhaled irritants on the nose.

Distribution and clearance of radioactive aerosol on the nasal mucosa.

The distribution and clearance of aerosolized radioactive technetium 99m pertechnate in physiologic buffered saline was analyzed in four human adult asymptomatic volunteers following delivery into one nostril in the same manner as for nasal challenge testing (i.e., 0.1 ml via a 251 DeVilbiss atomizer powered by a compressor delivering 0.10 +/- 0.01 gm/spray). For comparison, squeeze bottles and spray bottles from commercial sources, a 114 and a 127 DeVilbiss atomizer, and a pipette were employed. Lateral imagery via minicomputer processing was used to determine both distribution and clearance of the radiotracer. The counts after 1 minute were lower following pipette delivery than with the other devices. None yielded discernable , wide-spread distribution of aerosol throughout the nasal cavity. Following delivery from the 251 atomizer, mean clearance at 17 minutes was 60.0%. Similar clearance rates were obtained with the other spraying methods except for lower values with the squeeze bottle. Analysis of six hour clearance studies by linear regression showed a relatively rapid initial phase, which is probably due largely to mucociliary clearance, and a prolonged late phase related to the very slow disappearance of residual material located far anteriorly in the nose. Achieving good initial retention and rapid clearance of material deposited anteriorly in the nose are desirable attributes of devices employed for administering materials intranasally.

Immunotherapy for allergic disease.

Although immunotherapy initially was purely empirical, immunologic studies of treated patients in more recent years have shown several types of responses that might be beneficial to patients. Likewise, double-blind clinical trials have documented some clinical improvement if sufficiently large doses of certain allergens are administered to properly selected patients. The selection of patients for possible immunotherapy depends upon a large number of considerations, including the severity of their disease and response to simpler forms of treatment. More slowly absorbed allergen preparations may make immunotherapy less cumbersome and reduce risks. It is impressive that so many patients persist with such an inconvenient form of treatment. Perhaps this indicates that allergies are trivial only for those who don't have them.

Clinical spectrum of allergic and pseudoallergic drug reactions.

Among the many types of adverse effects of drugs, allergic reactions constitute a very significant minority, with respect to both their frequency and sometimes serious consequences. To keep the term "drug allergy" meaningful, it should be limited to those adverse drug reactions that are based on immune mechanisms or that can reasonably be presumed to have this basis. Pseudoallergic drug reactions, which will also be considered in this issue, have similar clinical manifestations and some common pathogenetic mechanisms, but the initiating event does not appear to involve a reaction between the drug or a drug metabolite and specific antibodies. Clinically, drug allergy is commonly observed in nonatopic as well as atopic people. Innumerable drugs have been reported to produce these types of reactions, but in many instances drug metabolites may be the actual culprits. Clinical manifestations of drug allergy also are legion. Unfortunately, essentially none of these is unique or specific for drug allergy, but it is important for clinicians to think of this very treatable condition along with other diagnostic possibilities. It is convenient and helpful to classify allergic reactions to drugs according to Gell and Coombs' four main types of hypersensitivity processes, but in many instances more than one mechanism may be involved, just as immune responses to most antigens generally are complex. Type I reactions are generally immunoglobulin (Ig) E-mediated, and clinical manifestations include urticaria, angioedema, respiratory symptoms, and anaphylaxis. Pseudoallergic reactions of the latter type are called anaphylactoid.(ABSTRACT TRUNCATED AT 250 WORDS)

Calculation of secretory antibodies and immunoglobulins.

There is increasing evidence for the secretion of IgG and IgE, as well as IgA, antibodies by the nasal mucosa. Because the former immunoglobulins lack an identifiable secretory piece, estimates of their secretion have been on their ratio to albumin or to total immunoglobulin of the same type in the nasal secretion as compared with serum. It is shown, however, that use of the ratio to albumin will result in large errors if the amount of antibody secreted by the nose is relatively small, and ratios based on total secretory Ig will, at least hypothetically, lead to error if antibodies with multiple specificities are being secreted. It is suggested that a more valid quantitation will be obtained from the expression (Formula: see text) where INS is an index of nasal secretion, Ab = antibody, Alb = albumin, N = nasal secretion, and S = serum.