High incidence of early anaphylactoid reaction to SAIMR polyvalent snake antivenom.

During a prospective study of 147 patients with snakebite presenting to a rural South African hospital, 13 of 17 patients (76%) treated with South African Institute for Medical Research (SAIMR) polyvalent antivenom experienced potentially severe early (anaphylactoid) reactions. The most common reaction was generalized urticaria (12; 71%), but 3 cases of angio-oedema (18%), 2 of bronchospasm (12%), and 2 of hypotension (12%) were also observed. Reactions were controlled with adrenaline, antihistamines, and resuscitation. All patients fully recovered from envenoming although the full dose of antivenom was not given to most. Indications for the use of this antivenom should be reconsidered and patients should be given antivenom in a high care setting if possible. Use of antivenom by lay people outside hospital should be discouraged and antivenom manufacturing processes could usefully be reviewed.

Renal effects of aprotinin after 24 hours of unilateral ureteral obstruction.

We have previously demonstrated that, after the release of 24-h unilateral ureteral obstruction (UUO), glomerular filtration rate (GFR), and renal blood flow (RBF) are reduced because of increased production of the potent vasoconstrictors thromboxane A2 (TxA2) and angiotensin II (ANG II). Captopril, which blocks ANG II production, increases GFR and RBF. Sequential administration of aprotinin, a kallikrein inhibitor, has an additive effect to further decrease renal vasoconstriction, even though kinins are generally thought to be vasodilators. Therefore, we assessed mechanisms by which aprotinin might improve renal function of previously obstructed anesthetized rats. When given alone to UUO rats, aprotinin improved renal hemodynamics. Since kinins stimulate TxA2 production by UUO kidneys perfused in vitro, our data suggest that aprotinin improved postobstructive function by decreasing kinin-stimulated TxA2 production, although this may not be its only effect. Aprotinin also improved postobstructive function, even if TxA2 formation was blocked with indomethacin. But when both ANG II and TxA2 formation were blocked by the simultaneous administration of captopril and indomethacin, aprotinin had no effect. This suggests that aprotinin may also affect ANG II formation. These pharmacological effects of aprotinin suggest that the kallikrein-kinin system may also contribute to postobstructive renal vasoconstriction by stimulating the production of both vasoconstrictor eicosanoids and ANG II.

Overlapping IgA and membranous nephropathy.

Four patients with overlapping IgA nephropathy and membranous nephropathy recently have been reported from two different medical centers in Japan. The authors describe two patients from the United States with the concurrence of IgA and membranous nephropathy and a third patient who may have the same overlapping glomerular lesions. All three patients had hematuria and nephrotic range proteinuria. Renal biopsy specimens from two of the patients revealed focal proliferative glomerular lesions, large mesangial and numerous subepithelial electron-dense deposits, exclusively mesangial intense immunostaining for IgA, and extensive granular capillary wall immunostaining for IgG. The third patient is a sibling of one of the other patients and was shown to have focal proliferative glomerular lesions, mesangial immunostaining for IgA, and numerous subepithelial electron-dense deposits. Pathogenic possibilities are discussed.

Fine needle aspiration cytology of pulmonary infarct.

The cytologic features of a pulmonary infarct diagnosed by fine needle aspiration (FNA) cytology are reported in a 54-year-old white man with a prior history of renal transplant surgery. Although the diagnosis of pulmonary embolus was unsuspected, FNA cytology suggested the correct diagnosis, which was confirmed by subsequent radiologic studies. This is believed to be the first reported case of pulmonary infarct diagnosed by FNA cytology. Cytologic features of the entity are discussed along with potential sources for a false-positive diagnosis of malignancy.

Focal glomerular sclerosis: contrasting clinical patterns in children and adults.

In a retrospective clinicopathological study, 48 kidney biopsy specimens from 16 children (mean age, 7 years) and 17 adults (mean age, 33 years) with histological evidence of focal glomerular sclerosis (FGS) were examined using light, immunofluorescence and electron microscopy. The histopathological findings were related to the clinical course of each patient. At the clinical onset of the disease, the nephrotic syndrome was seen more commonly in children (12/16) than adults (7/17), while the incidence of both hypertension (children 1/16 versus adults, 9/17) and renal insufficiency (children, 0/16 versus adults, 7/17) was greater in adults. Despite a shorter average follow-up, (adults 3 10/12 years versus children, 7 years), the incidence of hypertension (adults, 13/17 versus children, 7/16) and renal functional impairment (adults, 13/17 versus children, 3/16) remained greater in the adult patients. One child and three adults died in renal failure while two adults underwent transplantation and on requires regular dialysis therapy. Nine of 15 pediatric patients treated with corticosteroids experienced partial or complete remission in either their nephrotic syndrome or level of urine protein excretion, while just 3 of 6 adult patients treated with corticosteroids experienced a partial remission, but never became protein-free. There was an excellent correlation in all patients between the degree of functional renal impairment and the extent of glomerular and nonglomerular histopathological damage in the kidney. It is concluded that in the adults, FGS represents a more severe and progressive disease process and is less responsive to therapy.