Autonomic nervous system dysfunction associated with HIV infection in intravenous heroin users.

OBJECTIVE: To evaluate the presence of autonomic nervous system (ANS) involvement in HIV-positive drug users. DESIGN: We investigated 37 HIV-positive (and 18 HIV-negative controls) intravenous heroin users who were without symptoms and signs of autonomic or peripheral neuropathy. METHODS: The patients were clinically and immunologically assessed and subjected to a battery of five cardiovascular reflex function tests. RESULTS: The tests revealed ANS involvement in 22 HIV-positive subjects but only in one HIV-negative subject. Immunoglobulin (Ig) G and C1q immune complex levels were significantly higher in HIV-positive subjects with severe cardiovascular reflex function tests alteration compared to those with normal tests. In a follow-up of 17 HIV-positive subjects, nine presented deteriorated reflexes in the tests and higher IgG immune complex levels. CONCLUSIONS: The results confirm that, by using sufficiently sensitive tests, signs of preclinical autonomic neuropathy can frequently be found in HIV-positive intravenous heroin users, as previously observed in homosexual patients, and suggest the existence of an HIV-related autoimmune pathogenesis. Early diagnosis of ANS involvement could be important, since the presence of autonomic dysfunction could increase the risk of cardiorespiratory arrest during invasive procedures.

Abdominal placement of tube thoracostomy due to lack of recognition of paralysis of hemidiaphragm.

Tube thoracostomy is an invasive procedure that carries a risk of complications. We report a patient with liver cirrhosis, ascites and large left-sided pleural effusion, in whom a trocar type chest tube was inserted at the seventh left intercostal space in the midaxillary line. Chest roentgenogram revealed that the drainage tube was placed into the abdominal cavity because of a misrecognized elevation of the left hemidiaphragm. This case demonstrates that the placement of a tube thoracostomy requires caution in the identification of possible abnormalities which can lead to dangerous complications.

Amiodarone lung toxicity: role of pulmonary function tests.

Forty-three patients treated with amiodarone hydrochloride with an average daily dose of 204.7 +/- 79.4 mg/day for a mean period of 37.1 +/- 25.3 months, were studied by clinical examination, chest roentgenograms, pulmonary function tests and blood gas analyses. The habits of cigarette smoking were also recorded and expressed as cigarette pack/years. Pulmonary function tests did not show any differences from control subjects and no correlation was found between exposure to drug and lung function. However, one patient developed abnormalities in the chest X-ray (interstitial type) and a reduction of carbon monoxide diffusion capacity as a possible manifestation of amiodarone lung toxicity. Nine patients (22%) had a 20% decrease from normal in carbon monoxide diffusion capacity and three (7%) had a 15% decrease in total lung capacity. More treated patients had interstitial abnormalities in the chest X-ray (14%) than controls (5.5%). Although pulmonary function test abnormalities could be detected in patients taking amiodarone, they were not usually severe enough to interfere with gas exchange. Our results confirm the rarity of amiodarone lung toxicity when a low dosage is used, and suggest the advisability of periodical monitoring, including clinical examination, chest X-ray and pulmonary function tests in order to detect the earliest signs of amiodarone lung toxicity.

Amiodarone-induced thyroid dysfunction: diagnostic role of free serum thyroid hormone levels and pathogenetic significance of antithyroid antibodies.

Forty-six patients treated with amiodarone hydrochloride for a mean period of 41 +/- 3.5 months, with an average daily dose of 240 +/- 57 mg/day, have been studied. Thyroid function was assessed clinically and by laboratory tests, which included free-triiodothyronine (free-T3), free-thyroxine (free-T4) and thyrotropin. Antimicrosomal and antithyroglobulin antibodies were also looked for. Three patients (6.5%) were found to be hyperthyroid and two (4.3%) hypothyroid. Of the 41 clinically euthyroid patients, 19 (46.3%) showed one or more abnormalities in the thyroid function tests. In this group, only free-T4 was found significantly increased (p less than 0.05) as compared to both control populations. Antimicrosomal antibodies (titre greater than or equal to 1:1600) were present in 4 of 41 (9.7%) euthyroid patients, but not in hyper- or hypothyroid patients. There were no antithyroglobulin antibodies in any patients. Free hormone measurements have proved to significantly correlate with the clinical picture. Increases in free-T3 and free-T4 are the main features of hyperthyroidism, while a reduction in free-T4 serum level was specific for hypothyroidism. There are probably several mechanisms responsible for hyperthyroidism and some genetically controlled defects in synthesis and release of thyroid hormones might be among these. The presence of antithyroid antibodies could be due to deposits of amiodarone in the thyroid gland, with a consequent release of antigen from the follicle cell, but only in those patients with genetically determined defects in immunological surveillance could an autoimmune thyroiditis, with consequent hypothyroidism, develop.

Angiotensin-converting enzyme as a possible marker for lung toxicity in amiodarone-treated patients.

Since it has been observed that in vitro amiodarone induces morphological alterations in endothelial cells similar to those observed in patients with lung toxicity and that the angiotensin-converting enzyme (ACE) seems to be a marker for perturbation of the alveolar-capillary membrane, serum ACE concentrations have been determined in 44 patients, 23 treated with amiodarone (group A) and 21 treated with other anti-arrhythmic drugs (group B), before the beginning of treatment and after 7, 15, 30, 60 and 180 days. Serum ACE concentrations in group A were lower than the basal values (15.8 +/- 5.9 mU/ml) on day 7 (12.7 +/- 4.5 mU/ml) and were higher on day 60 (17.9 +/- 3.8 mU/ml), then returned to basal values by day 180 (15.9 +/- 5.5 mU/ml), but none of the differences were statistically significant. In group B, serum ACE concentrations were significantly higher than basal values (15.2 +/- 4.0 versus 14.2 +/- 3.5 mU/ml, p less than 0.05) only on day 15. In group A serum ACE concentrations were significantly higher than in group B only on day 60 (17.9 +/- 3.8 versus 14.7 +/- 4.5 mU/ml, p less than 0.025). During the period of the study none of the patients showed any clinical or radiological signs of lung toxicity or reduction of lung diffusion capacity for carbon monoxide (DLCO). Serum ACE levels were normal even in three patients who developed pulmonary fibrosis and in four whose DLCO was reduced by more than 20% from the basal values after the study was completed.(ABSTRACT TRUNCATED AT 250 WORDS)

[Secondary hypothyroidism with thyrotropic hormone deficiency. Presentation of a case and review of the literature]. / Ipotiroidismo secondario a deficit isolato di ormone tireotropo. Presentazione di un caso e revisione della letteratura.

A patient with clinical signs of hypothyroidism, low basal serum thyrotropin (TSH) and lack of response to releasing-factor (TRH) is described. The normal secretion of other anterior pituitary hormones both basal and after stimulation tests and the absence of hypophysial sella alterations found with computed axial tomography suggest the presence of a selective idiopathic TSH deficiency. The pituitary origin of this defect has been reported in literature only in five further patients, tested with TRH. The exact pathogenetic mechanism of these cases is still unknown: in the patient observed by the authors unresponsiveness both to TRH and to metoclopramide suggest an absence of TSH-producing pituitary cells or an alteration of the mechanism beyond the receptor and within the cell. However the possibility that such a secretion defect may represent a first sign of a pituitary tumor should not be excluded.

[Use of radioactive isotopes in the diagnosis of pulmonary tumors. Analysis of the results of 18 anatomically verified cases]. / Limpiego degli isotopi radioattivi nella diagnosi dei tumori polmonari. Analisi dei risultati di 18 casi controllati anatomicamente

18 cases of anatomically verified lung cancer were studied scintigraphically with microspheres of human albumin labelled with 99Tc, mercury bichloride (197Hg) and citrate of gallium (67Ga), to assess the diagnostic value of this technique. Using albumin microspheres, changes in the scintigraphic picture were obtained in 100% of cases, but inferior results were obtained with the two other tracers (gallium 75% and mercury bichloride 58.8%). The poor specificity of scintigraphy with albumin, which was changed in numerous non-neoplastic pathologies, removes all significance from this apparently brilliant result. From an overall assessment of all three scintigraphies, no increase in positivity percentages is obtained; the agreement of all three with respect to the neoplastic nature of the condition is however very good. Although possible conclusions are less favourable than those reported by other workers, the investigation with radioisotopes plays an important rôle in the diagnosis of lung tumours, in view also of its harmlessness and tolerability, although it is not enough on its own for diagnosis. Large series and constant anatomical and histological monitoring are needed before any definitive assessment can be attempted of the diagnostic value of this method.

[A case of oral localization of Crohn's disease. Review of the literature]. / Un caso di localizzazione orale del morbo di Crohn. Rassegna della letteratura.

A case of Crohn's disease with specific tonsillar, pharyngeal and laryngeal lesions is presented. The unusualness of this site was clear from the literature. Stress is laid on the ubiquity of lesions indicative of the systemic nature of the disease. The intestinal lesions contain a viral agent that can be transmitted to animals.

[Richter's syndrome. Presentation of a rare variant with regression of chronic lymphatic leukemia and review of the literature]. / Sindrome di Richter. Presentazione di una rara variante con regressione della leucemia linfatica cronica e revisione della letteratura.

The incidence of a lymphoreticular system malignancy in patients with chronic lymphocytic leukemia (CLL), Richter's syndrome (RS), is 3.3 to 10.6%. In 89 cases in the literature, the second neoplasm was either reticulum cell sarcoma or large cell diffuse histiocytic lymphoma (DHL), and there were 61 cases of Hodgkin's disease (HD). In a few cases the lymphoma was simultaneously diagnosed, for other cases an association with preexisting CLL was reported. Appearance of lymphoma was associated with leukemia regression for only 4 patients with DHL and 3 with HD. We report one case of B-lymphocyte CLL with macroglobulinemia, treated with melphalan and prednisone, in which DHL developed and the hematologic and histologic signs of CLL and of paraproteinemia remissed. Such patients might constitute a subgroup or a variant of RS. Since the non-Hodgkin malignant lymphomas (NHML) are considered to be monoclonal neoplastic expansion of the B-cell or T-cell lymphocytes, and since in some cases it has been proved that the proliferative cell clone was the same as that of the initial lymphoproliferative disease, RS could be a dedifferentiation or a transformation of CLL, resulting in an aggressive clinical course. The inclusion in this syndrome of CLL cases associated with HD is still controversial. Many of these cases could be giant cell pleomorphic lymphomas, while, on the contrary, in typical cases this association might be merely fortuitous.

[Sliding massive hiatal hernia: diagnosis using computerized axial tomography]. / Ernia iatale massiva da scivolamento: diagnosi mediante tomografia assiale computerizzata.

The radiological features of one patient, entirely asymptomatic, with a paracardiac mass in the right lower lobe, are presented. Computed tomography (TC) evaluation of the chest has shown with remarkable accuracy a massive hiatal hernia, containing the whole stomach and fatty omental tissue. This case confirms TC validity as an accurate and non invasive method in differential diagnosis of chest radiological opacities and its utility to identify seat and composition of diaphragmatic hernias.

[Excess mineralocorticoid syndrome secondary to nasal sprays containing 9 alpha-fluoroprednisolone]. / Sindrome da eccesso di mineralcorticoidi secondaria a spray nasali contenenti 9 alpha-fluoroprednisolone.

Two patients with signs of hypermineralcorticism and suppressed plasma aldosterone levels are reported. For both patients the use of a nasal spray containing 9 alpha-fluoroprednisolone had been ascertained, the withdrawal of which was followed by the normalization of the clinical picture as well as by the normal reactivity of the renin-aldosterone system. The endocrine studies excluded the presence of enzymatic defects or the hypersecretion of minor mineralocorticoids. The tests with angiotensin II and ACTH did not result in an increase in aldosterone, which instead increased in a significant way after metoclopramide, even with still suppressed basal values. Since the PRA was normal at the time of the metoclopramide test, a persisting inhibition of the factors directly controlling aldosterone secretion by 9 alpha-fluoroprednisolone could be possibly envisaged. An interesting findings was the onset of severe hypokalemia, conditioning rhabdomyolysis with myoglobinuria in patient 1, after a treatment of few weeks only. Since the factitious use of mineral corticoids is not taken into account, the need of an accurate collection of case history in the differential diagnosis of hyporeninemic hypoaldosteronism with hypokalemia is stressed.

[Budd-Chiari syndrome secondary to thrombosis of the inferior vena cava in myeloproliferative disease]. / Sindrome di Budd-Chiari secondaria a trombosi della vena cava inferiore in corso di malattia mieloproliferativa.

A case with abdominal pain, hepatosplenomegaly and ascites is reported. Ultrasonography and computed tomography showed a thrombus localized in the inferior vena cava at the confluence of the hepatic veins. The diagnosis of Budd-Chiari syndrome was made two years after clinical and laboratory findings appeared. The patient was affected by a Philadelphia-positive myeloproliferative disease that was the predisposing condition to the inferior vena cava thrombosis. We suggest that the diagnosis of Budd-Chiari syndrome must be considered in patients presenting conditions associated with thrombotic diathesis: so a suitable therapy can be started before an irreversible hepatic damage.

[Hypertrophic cardiomyopathy mimicking clinical picture of Budd-Chiari syndrome]. / Cardiomiopatia ipertrofica condizionante quadro clinico tipo sindrome di Budd-Chiari.

A case of a patient with clinical picture of hepatosplenomegaly, portal hypertension, dilatation of hepatic veins and inferior vena cava, without venous thrombosis or other causes of obstruction of right-sided heart, is described. This picture is compatible with the Budd-Chiari syndrome. Echocardiography has shown a hypertrophic cardiomyopathy causing relevant dilatation of both atria and it has allowed us to exclude the presence of a constrictive pericarditis. The hypertrophic cardiomyopathy is first considered as a cardiac cause of cirrhosis mimicking the Budd-Chiari syndrome.

[Is malignant mesothelioma of the pleura only an occupational disease?]. / Il mesotelioma maligno della pleura è solo una malattia professionale?

Ten cases of pleural malignant mesothelioma identified histologically at the Department of General Medicine in May 1983-June 1987, are examined in this paper. Occupational risk factors and clinical features are discussed. Only one patient (10%) was subjected to occupational risk of asbestos exposure (as a smith) while the other nine patients showed a negative anamnesis for direct or indirect asbestos exposure. However, one of these patients was a tram-driver. The patients' mean age was 69 years old. 7 patients were males. 7 patients were born in an industrialized urban environment, 3 were born in an agricultural environment: all had been living in Milan for many years. Pleural fluid cytology was only useful in the diagnosis of 2 cases. This study suggests that pleural malignant mesothelioma is a neoplasm which also affects people not exposed to asbestos at work and that its frequency is increasing. The most probable cause is environmental contamination by asbestos of urban industrialized areas. Thus, it is necessary to eliminate this mineral from all manufacturing processes in which asbestos is not indispensable.

[Anatomical study of the fibrosing action of Corynebacterium parvum in malignant pleural effusion]. / Documentazione anatomica dell'azione fibrosante del Corynebacterium parvum nei versamenti pleurici maligni.

Intrapleural injection of Corynebacterium parvum (CBP) has recently been used for the treatment of recurrent neoplastic pleural effusions and its mechanism of action has been suggested to be either a local fibrosis-stimulating effect or immunostimulation. The case is reported of a patient with pleuritis secondary to metastases of mammary carcinoma, treated with CBP plus methylprednisolone, who died five days after the treatment because of an acute myocardial infarction. The pathologic examination showed fibrinous pleuritis with an interconnecting network between the visceral and parietal pleura.

[Hemodynamic consequences of paracentesis, evaluated by a bloodless method, in liver cirrhosis]. / Conseguenze emodinamiche della paracentesi, valutate con metodica incruenta, nella cirrosi epatica.

Haemodynamic changes caused by paracentesis in cirrhosis of the liver with ascites have been studied, using systolic times in 11 patients. The use of a non-surgical technique made it possible to repeat the test after a 24 hour interval. The basal TCI and PEP, expressed as percentage variation of the normal frequency value, were significantly lowered, but the TET was substantially unchanged. The PEP/TET ratio was also reduced. The PEP and TCI tend to increase 24 hours after paracentesis, though not to a uniform degree, while the TET increases slightly and diminishes 24 hours later. The PEP/TET ratio gets significantly worse (P = 0.05) compared to values 24 hours after the end of paracentesis, but not in comparison to initial values. These data reveal that cardiac capacity and myocardial contractility undergo no significant variations either immediately after the end of paracentesis or 24 hours later. This procedure is therefore indicated in cases where ascites interferes with cardiorespiratory function. In addition to haemodynamic changes, significant variations in potassaemia and ammoniaemia needing accurate monitoring were observed in individual cases.

[Dissecting aneurysm of the thoracic aorta with paraplegic onset. Diagnosis using computerized tomography]. / Aneurisma dissecante dell'aorta toracica ad inizio paraplegico. Diagnosi mediante tomografia computerizzata.

A case of dissecting aneurysm of the thoracic aorta (De Bakey type III) which first presented as paraplegia of the lower extremities, and the diagnosis of which was confirmed by computerised tomography, is reported. Examination of the literature confirms the rarity of neurological complications especially as an initial symptom. The ischaemia involving areas supplied by the intercostal arteries must be the pathogenetic mechanism of both the paraplegia and the significant increase in sero-enzymes (CPK-MB). The case observed confirms the opinion of other authors that computerised tomography permits rapid diagnosis. As it is also easily performed and not invasive it represents an alternative to conventional angiography.

False positivity of tumor markers in pleural fluid of traumatic hemothorax.

Various biochemical parameters of pleural fluid have been employed to identify malignant effusions. However, many of them are also elevated in patients with nonmalignant conditions. We report on a patient with traumatic hemothorax, showing high pleural fluid concentrations of ferritin, tissue polypeptide antigen, and cancer antigen 125. This patient's pleural fluid also contained high levels of bilirubin and many macrophages containing phagocytized red blood cells, suggesting a local metabolism of hemoglobin. Our case confirms that some tumoral markers can give false positive results and suggests that their significance must be evaluated differently in bloody pleural effusions as compared with non-bloody pleural effusions.

[Still's disease in adults: diagnostic problems]. / Malattia di Still dell'adulto: problemi diagnostici.

Still's disease is a seronegative arthritis of children which, in a limited number of cases, can affect adults. The diagnosis of adult-onset Still's disease is characterized by high fever, arthritis and negative serologic tests for rheumatoid factor and antinuclear antibodies and by at least two minor symptoms (leukocytosis, evanescent rash, serositis, hepato- or splenomegaly, and lympho-adenopathy). Since many diseases present analogous manifestations and the adult-onset Still's disease is generally diagnosed by exclusion, we report two patients, aged 26 and 39, with Still's disease, the former with a classic clinical feature, the latter with a clinical feature characterized by severe hepatic abnormalities. The determination of histocompatibility antigens can be useful because some of them (HLA-DR4 in case 1 and HLA-DRw6 in case 2) are frequently associated with the adult-onset Still's disease. The role of anti-inflammatory therapy (acetylsalicylic acid, indomethacin, steroids) must be emphasized, whose efficacy can constitute the pathognomonic element on which the diagnosis of adult-onset Still's disease can be based in a proper clinical pattern.

Carbon monoxide-diffusing capacity in intravenous drug abusers: the effect of cigarette smoking and HIV infection.

A reduction in the Dco has been frequently found in intravenous drug addicts (IVDAs) and in subjects with HIV infection. Since also cigarette smoking decreases Dco, we studied a group of street IVDAs, who did not show respiratory symptoms and/or infiltrates on chest x-ray film. Sixty-two patients were presently smoking, 2 had never smoked. Twenty-seven were HIV-negative and 37 HIV-positive. Mean values for Dco (percent of predicted values) were 78 +/- 16.4 in HIV-positives compared to 97.9 +/- 17.6 in HIV-negatives (p < 0.0001) using smoking specific equations and 71.8 +/- 15.4 in HIV-positives compared to 80.7 +/- 13.4 (p < 0.0001) using non-smokers equations. Dco was < 80 percent in 19 of 35 (54.3%) HIV-positive subjects and in 4 of 26 (15.4%) HIV-negative subjects (p < 0.009) using predicted values for smokers, and in 28 of 35 (80%) HIV-positive subjects and in 6 of 26 (23.1%) HIV-negative subjects (p < 0.0001) using predicted values for non-smokers. These data suggest that Dco alterations observed in HIV-positive subjects are due, in absence of respiratory symptoms and/or chest x-ray abnormalities, to an interstitial pneumopathy due to HIV or to a subclinical pulmonary disease. We conclude that the knowing of smoking in IVDAs is useful, but the knowing of seropositivity is much more important, since a marked reduction of Dco in these subjects suggests an HIV-related lymphocytic alveolitis, an opportunistic infection or a malignancy.