[Severe hypercalcemia of unusual cause, looking for the culprit: Case report and review of the literature]. / Hypercalcémie sévère de cause inhabituelle, à la recherche du coupable : cas clinique et revue de la littérature.

INTRODUCTION: Hypercalcemia is not a rare event and can lead to severe consequences. Its main etiologies are primary hyperparathyroidism and neoplasic conditions. The iatrogenic etiology by vitamin D intoxication is more rarely found. CASE PRESENTATION: A 76-year-old finish woman comes to the emergency room for chest pain. Her medical history is impossible to specify due to the language barrier and initial confusion. She has severe hypercalcaemia (4.14mmol/L), renal insufficiency, cardiac arrhythmia later complicated by an ischemic cardiac episode. Clinic and biologic examinations initially guided the research towards a hematological and neoplasic pathology. The iatrogenic etiology will be permitted by the contribution of details on its medical history and treatment learnt secondly. She was treated for post-surgical hypoparathyroidism by dihydrotachysterol, a vitamin D derivative. The cessation of substitution, treatment with hydration and biphosphonates allowed the rapid correction of hypercalcemia. DISCUSSION: Dihydrotachysterol intoxication is a rare etiology of hypercalcemia. Because of the longer half-life of this molecule, the risk of hypercalcemia seems to be greater than with other vitamin D derivatives. This molecule, withdrawn from the French market in 1982, is not detected by the dosage of 25 and 1.25 OH vitamin D. CONCLUSION: We report an original case of intoxication by dihydrotachysterol. The risk of hypercalcemia encountered with this molecule must be known. The close medical follow-up recommended in case of hypoparathyroidism seems to be particularly necessary in case of supplementation by this molecule.

Osteolytic phaeohyphomycosis caused by Phialemonium obovatum.

Phialemonium obovatum was found to be the cause of nosocomial osteomyelitis in a 41-year-old man after sustaining a nonpenetrating injury to his lumbar and cervical region. Histologic examination of fragments of disk and bone from L3-4 hemilaminectomy showed multiple fragments of fibrocartilage with focal necrosis, chronic inflammation, and granulation tissue formation. Sections stained with Gomori's methenamine silver procedure showed multiple fungal elements in necrotic areas consisting of irregularly branched, hyaline septate hyphae having swollen cells, and occasional yeastlike cells. The use of Fontana-Masson silver stain showed the presence of melanin in cells walls and septa of the hyphae. Phialemonium obovatum was isolated when the ground tissue from disk and bone from L3-4 was cultured on biphasic brain-heart infusion medium. Colonies were moist, off-white to ochraceous with a characteristic green, diffusible pigment on the reverse side. The isolate grew well up to 40 degrees C. It formed characteristic adelophialides without conspicuous collarettes and basal septa and produced smooth, one-celled, hyaline, and obovate conidia.

[Role of ambulatory blood pressure measurement in the evaluation of the cardiovascular load in high altitude workers]. / Place de la mesure de la pression artérielle en ambulatoire dans l'évaluation de la charge cardiovasculaire de salariés travaillant en haute altitude.

UNLABELLED: This study evaluates ambulatory blood pressure ABP measurement as a technique for measuring the cardiovascular load in maintenance mechanics working on mechanical lifts at altitudes of over 2,500 meters (stress due to altitude and intensive static and dynamic work). METHOD: 25 normotensive workers were studied during real working conditions. Each subject underwent a maximal stress test, and echocardiography. An ABP recording (Spacelab 90207) with BP measurement every 15 minutes and continuous heart rate (HR) monitoring (Essilor IFC85), during 24 hours were performed on the same day. ANALYSIS: study of BP levels and their factors of variation, comparison of this data with continuous HR measurements, and with results of the stress test and echocardiography. RESULTS: even in difficult conditions (while balancing on cables and cable towers), ABP measurements is possible (less than 10% missing values). Systolic (SBP) and diastolic (DBP) blood pressure and HR values adjusted for age are significantly higher during work activity (9:00-12:00, 14:00-15:00) in these subjects than in reference normotensive subjects. ABP did not differ significantly between different types of work while the equivalent mechanical load (work load that gives a stress test HR equal to the mean HR during work) reveals a different between work activities. At night SBP remains higher and HR values lower than in control subjects. In comparison with reference criteria, 3 subjects were considered as having an abnormally high ABP during the daytime. ABP results were not linked with number of years in the profession nor with the altitude at which the subject worked or lived. Although 40% of subjects have a left ventricular mass index greater than 135 g:m2, there is no link between ultrasound and ABP parameters. CONCLUSION: while ABP measurement seems possible in this type of professional activity, BP values do not appear to be correlated to work level measured. The absence of correlation with left ventricular mass, suggests that the process of cardiovascular adaptation is different from that in even moderately hypertensive subjects.

Diagnostic assessment of an enzyme-linked immunosorbent assay for human and canine blastomycosis.

An enzyme-linked immunosorbent assay (ELISA) for blastomycosis was evaluated with 65 human sera from culturally or histologically proven cases of blastomycosis, 53 sera from humans with heterologous infections, and 115 sera from apparently normal people. The diagnostic value of the ELISA was compared with that of the widely used complement fixation (CF) and immunodiffusion (ID) tests. The assay gave a sensitivity of 80% and a specificity of 98% with a minimal positive titer of 1:16. In contrast, the CF and ID tests demonstrated sensitivities of only 40 and 65%, respectively, and both were 100% specific. It was concluded that ELISA titers of 1:32 or greater are indicative of active blastomycosis, whereas lower titers, which might represent cross-reactions, were considered suggestive of the disease. The specificity of low titers should be confirmed by immunodiffusion tests or from the study of serial serum specimens. Preliminary studies with sera from 6 dogs with active blastomycosis and 31 asymptomatic dogs revealed an ELISA sensitivity of 100% and a specificity of 97% when a 1:8 cutoff titer was used. Although a wide range of titers was obtained in both human and canine specimens, no single titer could be relied on to reflect the clinical form of disease. However, a four-fold-or-greater reduction in titer for serial specimens appeared indicative of a favorable prognosis.

Rapid and reliable method for production of a specific Paracoccidioides brasiliensis immunodiffusion test antigen.

Previously published methods to produce Paracoccidioides brasiliensis antigens for serological tests have yielded antigens of inconsistent quality and have involved the use of special semisynthetic media and growth periods of 1 to 3 months to yield suitable reagents. A simple procedure that uses commercially available potato glucose agar and either SABHI broth (Difco Laboratories) or Trypticase soy broth (BBL Microbiology Systems) inoculated with the mycelial form of P. brasiliensis consistently yielded high-titer antigens in 2 weeks or less. This new method permits the almost exclusive production of an antigen identical to the specific E antigen described by Yarzabal (Yarzabal et al., Sabouradia 14:275-280, 1976) and the apparently equivalent specific antigen 1 described by Restrepo and Moncada (A. Restrepo and L. H. Moncada, Appl. Microbiol. 28:138-144, 1974). In the immunodiffusion test, the rapidly produced antigen demonstrated a sensitivity of 90% by detecting antibody in sera from 103 of 114 proven cases of paracoccidioidomycosis. The specificity of this antigen was 100% because none of 139 sera from patients with heterologous mycotic diseases demonstrated diagnostic precipitins against the P. brasiliensis antigen. In the complement fixation tests, the rapidly produced antigen was not as suitable as the one prepared by the method of Restrepo-Moreno and Schneidau (A. Restrepo-Moreno and J. D. Schneidau, Jr., J. Bacteriol. 93:1741-1748, 1967).

Comparative evaluation of commercial Premier EIA and microimmunodiffusion and complement fixation tests for Coccidioides immitis antibodies.

A total of 409 serum and cerebrospinal fluid specimens from human subjects with proven coccidioidomycosis, with other infections, or with no apparent illness were tested for antibodies to Coccidioides immitis by the Premier EIA (Meridian Diagnostics, Inc., Cincinnati, Ohio), which tests for immunoglobulin G (IgG) and IgM responses to coccidioidal antigens, and by the conventional complement fixation (CF) or immunodiffusion (ID) assays for antibodies corresponding to those detected by the tube precipitin (TP) or CF tests. Of the 409 specimens, 47 were from persons with confirmed coccidioidomycosis and all were positive for C. immitis antibodies in IDCF tests and enzyme immunoassays (EIAs) for both IgG and IgM. The EIA for detecting both IgG and IgM antibodies proved to be sensitive for detecting coccidioidomycosis case sera positive by the IDCF, IDTP, and CF tests. Maximal sensitivity for diagnosing coccidioidomycosis is dependent upon detection of both IgG and IgM antibodies in the EIA. The EIA, however, was not absolutely specific, since some sera from patients with confirmed blastomycosis and some from patients with noncoccidioidal disease produced false-positive reactions.

Development of specific fluorescent-antibody test for tissue form of Penicillium marneffei.

The diagnosis of penicilliosis marneffei can be difficult because the clinical manifestations mimic those of tuberculosis, histoplasmosis, and other mycotic infections. Furthermore, the tissue form of Penicillium marneffei can be confused with those of Histoplasma capsulatum and Cryptococcus neoformans. To facilitate the rapid detection and identification of P. marneffei in clinical materials, we sought to develop a specific indirect fluorescent-antibody (IFA) reagent for this dimorphic pathogen. Preliminary IFA studies with yeast-like cells (fission arthroconidia) of P. marneffei indicated that these cellular elements stained with antiglobulins against culture filtrate antigens and whole yeast-like cellular antigens. Both types of antiglobulins reacted with the yeast-like cells of P. marneffei and with H. capsulatum, but not with their respective mycelial forms. The antiglobulins also failed to react with the yeast and hyphal forms of a variety of other heterologous fungi. Specific antiglobulins useful in an IFA test for identifying P. marneffei yeast-like cells in culture or in clinical materials were produced by adsorptions with yeast-form cells of H. capsulatum. The yeast-like culture filtrate antigens of P. marneffei are preferred for use in the production of the specific antiglobulins because they stained P. marneffei yeast-like elements more intensely than antiglobulins produced against intact yeast-like cells.

The value of the Premier enzyme immunoassay for diagnosing Blastomyces dermatitidis infections.

One hundred and three sera drawn from 20 proven and 65 suspected cases of blastomycosis were examined concurrently with the enzymes immunoassay and microimmunodiffusion tests for the 'A' antibody specific for Blastomyces dermatitidis. Results indicated that all 20 proven sera were positive by both these tests. Thirteen of the 65 sera from suspected blastomycosis cases were positive by the enzyme immunoassay only, whereas none reacted positively in the micro-immunodiffusion test. Eighteen sera from apparently normal subjects, and patients with heterologous fungal and HIV infections were also tested by both tests. The sensitivity and specificity of the enzyme immunoassay test was 100% and 85.6%, respectively. The micro- immunodiffusion test was 100% sensitive and specific. In light of the fact that the enzyme immunoassay test is not entirely specific, a positive result should be confirmed by either a positive culture, histopathology or micro-immunodiffusion test.

Immunohistologic identification of Aspergillus spp. and other hyaline fungi by using polyclonal fluorescent antibodies.

Isolation and identification of pathogenic Aspergillus and Fusarium spp. from clinical materials provide the most accurate means for establishing a diagnosis of infections by these molds. Such efforts, however, are not always successful. Histologic diagnosis also has its limitations. In vivo the hyphae of Aspergillus and Fusarium spp. are very similar and their in situ manifestations are not pathognomonic. To improve the histologic diagnosis of infections by Aspergillus and Fusarium species, we developed polyclonal fluorescent-antibody reagents to Aspergillus fumigatus and Fusarium solani and evaluated their diagnostic utilities. Our studies revealed that A. fumigatus and F. solani share epitopes not only with one another but also with other Aspergillus and Fusarium spp. as well as with Paecilomyces lilacinus and Pseudallescheria boydii. Adsorption of the A. fumigatus conjugate with cells of Fusarium proliferatum and F. solani and F. solani antiserum with cells of Aspergillus flavus resulted in reagents that distinguished Aspergillus spp. from Fusarium spp. but that still cross-stained P. lilacinus and P. boydii. Adjunctive use of a specific P. boydii conjugate enabled the identification of Aspergillus spp., Fusarium spp., P. lilacinus, and P. boydii in formalin-fixed tissue sections from 19 humans with culture-proven cases of mycotic infection.

Diagnostic antigenemia tests for penicilliosis marneffei.

Disseminated penicilliosis marneffei is an emerging opportunistic mycosis seen in severely immunocompromised human immunodeficiency virus (HIV)-infected patients and is caused by the dimorphic fungus Penicillium marneffei. Early diagnosis and treatment improve clinical outcome. Proper diagnosis is complicated by nonspecific signs and symptoms and by difficulties in histologic recognition and species identification of the pathogen. Since no established immunodiagnostic methods for penicilliosis marneffei are available, we attempted to develop separate immunodiffusion tests to detect P. marneffei antigens and antibodies in patient serum specimens and a latex agglutination test for antigenemia. Antigens consisted of 2-week-old fission arthroconidial filtrates produced in Pine's broth at 37 degrees C. Rabbit antisera were prepared against the 10 x -concentrated filtrate antigens. Studies were carried out with 17 serum specimens from HIV-seropositive adult Thai patients with penicilliosis marneffei and 15 control serum specimens from Thai persons free of HIV and P. marneffei infection. The immunodiffusion tests detected P.marneffei antigenemia in 10 (58.8%) of 17 patients, whereas the latex agglutination test detected antigenemia in 13 (76.5%) of the 17 patients. Antibody was demonstrated in only 2 of the 17 patient sera. All of the tests appeared to be highly specific, since none were positive with sera from 15 Thai control patients, six serum samples containing cryptococcal antigen, or six urine specimens positive for Histoplasma polysaccharide antigens.

Comparative evaluation of the Premier enzyme immunoassay, micro-immunodiffusion and complement fixation tests for the detection of Histoplasma capsulatum var. capsulatum antibodies.

A total of 178 sera, including 68 from proven cases of histoplasmosis (65 positive for the presence of Histoplasma capsulatum var. capsulatum antibodies and three positive for antigen), 93 from patients with suspected histoplasmosis but with no laboratory evidence of H. capsulatum var. capsulatum infection, 14 from humans with heterologous fungal and non-fungal infections and three from normal individuals, were tested for IgG H. capsulatum antibodies and M or M and H precipitins by enzyme immunoassay (EIA) (Meridian Diagnostics, Cincinnati, OH, USA) and microimmunodiffusion (MID) respectively. Sixty-three of the 68 histoplasmosis case sera demonstrated IgG antibody, and 65 of 68 demonstrated the presence of specific precipitins in the MID test. Nine positive case sera, when tested with the Laboratory Branch complement fixation (LBCF) test, reacted positively to whole yeast and histoplasmin antigens (titres 1:8 to 1:512). Three histoplasmosis case sera repeatedly tested negative for IgG, specific precipitins and complement-fixing antibodies, whereas they were positive for Histoplasma antigen. Eighteen of 95 sera from patients without evidence of histoplasmosis demonstrated IgG antibody in the EIA only. Among these positive sera, three out of three cases of aspergillosis and three out of five cases of blastomycosis were confirmed. Sera from HIV-infected and healthy individuals did not show IgG or M and/or H antibodies to H. capsulatum. Ninety-three sera were negative by both EIA and MID. The EIA for IgG was less sensitive (97%) than MID (100%). The specificity of EIA and MID was 84% and 100% respectively.

Evaluation of a commercial enzyme immunoassay for the detection of cryptococcal antigen.

A total of 143 cerebrospinal and serum samples, from proven and suspected cases of cryptococcosis, were concurrently examined using a recently introduced enzyme immunoassay (EIA Premier, Meridian Diagnostics, Inc., Cincinnati, OH, USA) and three latex agglutination (LA) procedures (Immunomycologics, Inc., Norman, OK, USA; IBL, Inc., Cranbury, NJ, USA and a non-commercial LA test). Of these 143 specimens, 115 were negative for cryptococcal antigen (CrAg) with the EIA and LA tests. The remaining 28 specimens were evaluated by the LA tests, and all were positive for CrAg (with titres ranging from 1:2 to 1:8192). Of these 28 LA-positive specimens, 26 were also tested by the EIA. This procedure detected CrAg in 23 specimens (88.5%), with antigen levels ranging from 1:4 to 1:266,857. There were 3 LA-positive specimens (tires 1:4 to 1:32) which were negative by the EIA procedure (10.7%). One LA-negative specimen demonstrated CrAg (titre 1:30) by the EIA procedure. The sensitivity of the EIA and LA tests was 85.2 and 100%, respectively. The specificity of the LA test was 100%, whereas that of the EIA was 97%. The agreement among laboratories for testing the specimens with the three LA tests was 100%.