Fever of unknown origin: classic and associated with human immunodeficiency virus infection. a comparative study.

Fever of unknown origin (FUO) associated with HIV infection is different from classic FUO. Relevant etiologies, procedures and time to diagnosis were analyzed. Patients admitted with FUO from 1991 to 1996 were prospectively followed. Thirty with classic FUO (group I) and 46 with FUO and HIV (group II) were included. Data on diagnosis, time to achieve it, and procedures were registered. Diagnosis was obtained in 87% and 93% of cases in groups I and II. Infections were the most frequent cause in group II. Collagen diseases were found in group I and absent in group II. Prevalence of neoplasia was similar. Mean time to diagnosis was near 5 weeks. In HIV the predominant diagnostic method was the Lowenstein culture. Invasive methods were similarly employed. It is concluded that predominance of Mycobacteria and absence of collagen diseases make FUO associated with HIV a different form of FUO. No differences were found in approach and time to diagnosis.

Mycobacterium thermoresistible recovered from a cutaneous lesion in an otherwise healthy individual.

This is the first report of coinfection by Mycobacterium thermoresistible and Mycobacterium fortuitum and only the fifth case of human infection by M. thermoresistible reported in the world literature.

Relationship of basal and postprandial intraduodenal bile acid concentrations and plasma cholecystokinin levels with abdominal pain in patients with chronic pancreatitis.

Abdominal pain in patients with chronic pancreatitis has been related to an increase in plasma cholecystokinin (CCK) levels. The aim of the study was to disclose the relation of the altered response with the low intraduodenal bile acids levels found in these patients. Twenty patients with chronic pancreatitis were classified into groups I (n = 11) and II (n = 9) according to the presence or absence of pain. Intraduodenal trypsin and bile acids concentrations and plasma CCK levels were measured before and 30, 60, and 90 min after a test meal. Comparisons between values in both groups were carried out. Correlation of intraduodenal trypsin and bile acids with plasma CCK was analyzed. Patients with pain exhibited significantly lower intraduodenal trypsin levels at 30 and 90 min and lower basal and postprandial intraduodenal bile acids levels than patients without pain. In patients with pain, basal and postprandial plasma CCK levels were significantly higher than in patients without pain. A negative correlation was demonstrated between intraduodenal bile acids and plasma CCK. In patients with chronic pancreatitis and pain, a reduction in intraduodenal postprandial trypsin and basal and postprandial bile acids concentrations, as well as an increase in basal and postprandial plasma CCK levels, was encountered. A negative correlation between intraduodenal bile acids and plasma CCK concentrations was detected that may be implicated in the pathogenesis of pain.

Postprandial cholecystokinin response in patients with chronic pancreatitis in treatment with oral substitutive pancreatic enzymes.

Cholecystokinin (CCK) response to a test meal should be increased in patients with pancreatic insufficiency, as trypsin is absent from the duodenum. If pancreatic enzymes are added, a restoration of the inhibitory feedback should result in lower levels of CCK. Ten patients with chronic pancreatitis and steatorrhea were studied. CCK basal and postprandial levels were evaluated the day before and 45 and 90 days after treatment with oral pancreatin. Twelve healthy volunteers were included as reference group. CCK basal levels did not vary. CCK response to a test meal was increased in patients before treatment and diminished when oral enzymes were maintained for months even after three days of therapy withdrawal. We conclude that long-term therapy with oral enzymes induces changes in CCK response that do not regress after three days of treatment suspension.

Bilirubinate granules: main pathologic bile component in patients with idiopathic acute pancreatitis.

OBJECTIVE: The aim of this study was to evaluate the main pathologic component of bile obtained by biliary drainage in patients with acute idiopathic pancreatitis and therapeutic implications. METHOD: Eighteen patients diagnosed with idiopathic acute pancreatitis underwent biliary drainage. Microscopic evaluation of bile was performed and pathologic components were classified in cholesterol microcrystals, bilirubinate granules, and calcium microspherolites. RESULTS: Five patients showed no abnormalities. In 11 patients, bilirubinate granules were found, cholesterol microcrystals in two, and Giardia lamblia in two. CONCLUSION: Bilirubinate granules are the main pathologic component of bile in patients with acute idiopathic pancreatitis. Cholecystectomy is the preferred therapeutic approach.

Osteomyelitis due to Mycobacterium haemophilum in a cardiac transplant patient: case report and analysis of interactions among clarithromycin, rifampin, and cyclosporine.

We describe a case of osteomyelitis due to Mycobacterium haemophilum in a cardiac transplant recipient and review the two other reported cases of M. haemophilum infection in cardiac transplant patients. Our patient had an excellent response to a prolonged course of therapy with clarithromycin and rifampin. We examine in detail the interactions between these two antibiotics and cyclosporine, including the apparently offsetting effects of clarithromycin/rifampin combination therapy on blood levels of cyclosporine.

Postprandial glucose-dependent insulinotropic polypeptide and insulin responses in patients with chronic pancreatitis with and without secondary diabetes.

OBJECTIVE: To study GIP and insulin release after a test meal in patients with chronic pancreatitis with and without secondary diabetes mellitus. METHODS: 28 patients with chronic pancreatitis were classified in groups I and II according to the presence or absence of secondary diabetes mellitus. Twelve healthy subjects were included as controls. After a test meal plasma GIP levels and serum insulin levels were determined at 0, 30, 60, 120 and 180 min. RESULTS: A significant diminished GIP response was found in the groups of patients with respect to the control group. No association could be detected with severity of pancreatic insufficiency. Higher values of GIP were demonstrated at 60 and 120 min in patients without diabetes than in patients with it. CONCLUSIONS: An abnormal GIP response is present in cases of chronic pancreatitis irrespective of the presence or severity of pancreatic insufficiency. This response is further affected if secondary diabetes mellitus is present.

Otitis media and mastoiditis due to Mycobacterium fortuitum: case report, review of four cases, and a cautionary note.

Mycobacterium fortuitum is a rarely reported cause of otitis media and mastoiditis. We report such a case recently seen at our institution and review the four previously published cases of this disease entity. Amikacin is recommended in the current medical literature as empirical treatment of disease due to M. fortuitum, but the isolate from our patient showed high-level resistance to amikacin, which is rare in clinical isolates of this species; this resistance was probably related to prior treatment with topical aminoglycosides. Our patient's infection responded to a 12-month course of therapy with clarithromycin and trimethoprim-sulfamethoxazole.

Specific inactivation of the fourth complement component. II. In vitro studies.

The fourth complement component (C4) inactivator obtained from nurse shark serum was used to inactivate C4 in fresh sera of various mammalian species. These hemolytically inactive sera, which contained the remaining eight complement components in unaltered form, were used (i) as a source of the first complement component (C1) for the generation of sensitized sheep erythrocytes (EA)-C1 and (ii) as a homologous reagent for the measurement of C4 activity with EA-C1 or EA in fresh, normal serum of guinea pigs, humans, dogs, and pigs.

Specific inactivation of the fourth complement component. I. In vivo studies.

Intravascular injection of guinea pigs with the fourth complement component (C4) inactivator from shark serum resulted in severe serum C4 depletion that lasted for several hours. Active and direct passive Arthus reactions did not develop or were extremely mild in such C4 inactivator-treated animals as judged by gross and histological observation. In consideration of the specificity of the C4 inactivator, its independence of cofactors, and its failure to generate biologically active materials in the process of C4 inactivation, it is concluded that complement-dependent immune injury can be suppressed or avoided by interruption of the complement cascade at a single early step. The depression of the Arthus reaction beyond the time of C4 recovery prompted quantitative speculations concerning (i) the in vivo rate of C5a generation under conditions of limited C4 supply and (ii) the "saturation" of immune complexes. This view is supported by in vitro demonstration of functional inactivation or "saturation" of immune precipitates by repeated incubation with fresh guinea pig complement. It seems therefore conceivable that even temporary complement inactivation may have a profound beneficial effect on complement-dependent immune injuries.