Rhabdomyolysis caused by the moderate CYP3A4 inhibitor fluconazole in a patient on stable atorvastatin therapy: a case report and literature review.

WHAT IS KNOWN AND OBJECTIVE: Rhabdomyolysis is a severe potential adverse drug reaction of statin therapy. We report a case of rhabdomyolysis due to drug-drug interaction (DDI) between atorvastatin and fluconazole and review the literature. CASE SUMMARY: A 70-year-old woman received atorvastatin for hyperlipidaemia without any problem for 4 years. When intravenous fluconazole was added for treating a fungal infection, rhabdomyolysis developed 2 weeks later. Removal of atorvastatin led to the resolution of her rhabdomyolysis. WHAT IS NEW AND CONCLUSION: Our case demonstrates that in some subjects even a moderate CYP3A4 inhibitor such as fluconazole may lead to rhabdomyolysis in subjects receiving a statin.

A leucine zipper motif in the cytoplasmic domain of gp41 is required for HIV-1 replication and pathogenesis in vivo.

A leucine zipper motif is conserved in the cytoplasmic domain of glycoprotein gp41 (gp41c) of all HIV-1 subtypes, but is not present in HIV-2 or SIV. The second leucine residue of the leucine zipper was mutated (L95R) to determine the role of this motif in HIV-1 replication and pathogenesis. The L95R mutant replicated to wild-type levels in activated peripheral blood mononuclear cells and CEMx174 cells. However, L95R replication was impaired in SupT1 cells and in the SCID-hu Thy/Liv mouse. Although the infectivity of wild-type virions and that of L95R mutant virions were equally sensitive to heat treatment, we found that L95R produced more defective virions, due to reduced surface expression and virion incorporation of the env glycoprotein. These results suggest that the L95 residue in the leucine zipper of gp41c of HIV-1 plays an important role in the env expression and virion incorporation that is required for viral replication and pathogenesis in the SCID-hu Thy/Liv mouse. The leucine zipper motif in gp41c may provide a novel anti-HIV-1 target.

The developments of mass urinary screening in Taiwan.

A program of mass urinary screening of elementary and junior high school students has been in operation since August 1990 in Taiwan Province. This program is done once a semester, i.e., twice a year. In the first 3 years, the total number of elementary and junior high school students to be examined in each semester was approx. 2.7 millions. From August 1993, the total number increased to 3.1 millions because the senior high and senior vocational school students were added. The procedures can roughly be divided into five parts: The first part is first urinary screening. The second part is the second urinary screening. The third part is so called the third examination namely serological examination. Life guidance is introduced in the fourth part. The last part is the follow-up system. All the procedures and details will be discussed later.

A retrospective drug utilization evaluation of antihyperlipidaemic agents in a medical centre in Taiwan.

OBJECTIVE: The purpose of this study was to retrospectively evaluate the prescribing of antihyperlipidaemic agents in an 800-bed medical centre in southern Taiwan. METHODS: A retrospective study based on reviewing medical records was conducted using a computerized database. We randomly selected 344 patients (age range 5-85 years) who received an antihyperlipidaemic agent between 1 April 1994 and 30 September 1994 and reviewed their medical records. All the related data from the date when the antihyperlipidaemic agent was first prescribed to 31 December 1994 was assessed. Usage guidelines for antihyperlipidaemic agents were defined by referring to the literature and specialist opinion. RESULTS: Two hundred and twenty-two patients (64.5%) were treated with antihyperlipidaemic agents in accordance with the usage guidelines. In addition, most of the treatments complied with the regulations laid down by related health insurance programmes. The other 122 cases (35.5%) failed to meet any of the indications of the usage guidelines. Only 102 patients (29.7%) had their baseline lipid profiles examined and 117 patients (34%) had their baseline liver function tested. Over all, very few cases had lipid profiles and liver function tests every 3 months while taking antihyperlipidaemic agents. Patients who had been prescribed antihyperlipidaemic agents for more than 1 year were evaluated to assess the effectiveness of their pharmacological therapy. The prescribed doses were found to be lower than recommended in the general literature except for patients who received lovastatin and pravastatin. CONCLUSIONS: There are many treatment guidelines for hypercholesterolaemia in north America and Europe. This study revealed that a large proportion of antihyperlipidaemic agents used in our patient population did not comply with these general recommendations. Although the reasons for not complying with usage guidelines need to be further investigated, our study findings may well serve as the basis for further quality management and pharmacoeconomic analysis.

Cadmium inhibits DNA strand break rejoining in methyl methanesulfonate-treated CHO-K1 cells.

The cogenotoxicity of Cd has been recognized. This effect may stem from Cd inhibition of DNA repair. We studied the effects of Cd on DNA repair of methyl methanesulfonate (MMS)-damaged Chinese hamster ovary cells (CHO-K1) by single-cell alkaline electrophoresis. The results indicate that in the presence of Cd, DNA strand breaks accumulated in MMS-treated cells. Using hydroxyurea (Hu) plus cytosine-beta-D-arabinofuranoside (AraC) to block DNA polymerization, DNA strand breaks accumulated and Cd had little inhibitory effects on these accumulations. However, Cd inhibited the rejoining of these DNA strand breaks, which could be rejoined 6 hr after release from Hu plus AraC blockage. These results indicate that the potency of Cd inhibition of DNA repair replication and/or ligation may be greater than the inhibition of DNA adduct excision. To further elucidate this mechanism, we used an in vitro cell-free assay system to analyze the Cd effects on DNA repair synthesis, DNA polymerization, and DNA ligation. We have shown a dose-dependent inhibition of these three activities by Cd in CHO-K1 cell extract. The IC50s of Cd were 55, 26, and 10 microM, respectively. Moreover, Cd inhibition of DNA ligation in cell extract could be recovered partially by thiol compounds such as glutathione, beta-mercaptoethanol, dithiothreitol, and metallothionein. Since both in vivo and in vitro studies demonstrated that Cd was more effectively involved in interfering with the DNA ligation step and that thiol agents could partially remove Cd inhibition of DNA ligation, we speculate that part of the Cd inhibition of DNA repair may be through binding of Cd to the proteins participating in DNA ligation.

State of mutational alterations of p53 and retinoblastoma susceptibility genes in papillomavirus-negative small cell cervical carcinomas.

Genetic aberrations were examined to assess the possible roles that p53 and retinoblastoma susceptibility genes might have played in the development of small cell cervical carcinomas. Cervical cancer tissues from 12 patients with small cell cervical carcinoma that were free of human papillomavirus were analyzed. The presence of mutational alterations were examined by polymerase chain reaction-single-strand conformation polymorphism and by direct DNA sequencing. None of 12 small cell cervical carcinomas were found to contain mutations in regions of p53 and retinoblastoma susceptibility genes that were functionally important and where most mutations, in human tumors have been found. Furthermore, there was no evidence indicative of loss of heterozygosity of chromosome region 17p13 (in which p53 is located) in these tumors. These data seem to suggest that whereas mutant type of p53 and retinoblastoma susceptibility genes may exhibit "oncogenic" function in many human tumors, mutational inactivation of these genes may not be an important feature in the carcinogenic development of human papillomavirus-negative small cell cervical carcinomas.

Prevalence of human papillomavirus DNA sequences in an area with very high incidence of cervical carcinoma.

To improve our understanding of the relationship and possible associations between human papillomavirus (HPV) infection and the development of cervical malignancies, the presence of multiple types of HPV DNA sequences in cervical carcinoma was determined in Chinese citizens living in two different geographical locations where the incidences of cervical carcinoma are either relatively low or extremely high. HPV DNA sequences were found in 88.5% (54 of 61) of Chinese cervical carcinoma patients living in Taiwan, where the prevalence of cervical carcinoma is 23.7 per 100,000 women. In contrast, in LueYang in Shanxi province, an area with a very high prevalence of cervical carcinoma (1,026 per 100,000 women), only 57.1% (28 of 49) of Chinese cervical carcinoma patients were found to be infected with genital HPV. This result seems to suggest that either the presence of HPV may have different implications in different populations or HPV infection may not be the only factor that determines the development of cervical carcinoma, at least in certain geographical areas. Recently acquired transient or chronic persistent HPV infection may have a different outcome with regard to cervical carcinogenesis. Alternatively, other factors, such as host determinants, may play a role in the development of cervical carcinoma.

Fetal cells in the maternal circulation during first trimester in pregnancies.

To investigate the presence of fetal cells in the maternal circulation during early pregnancy, the polymerase chain reaction was used to test the presence of human Y chromosome-specific ZFY and SRY gene DNA sequences in maternal peripheral blood specimens from 19 women carrying male fetuses and 12 women carrying female fetuses. The presence of fetal cells was suggested as early as 6 weeks gestation in 1 of the 19 women bearing male fetuses. Fetal cells were present in the maternal circulation of 15 of the 19 women by 9 weeks gestation, and in only 1 of the 19 were fetal cells not detected until the 12th week after conception. These results suggest that identification of fetal cells in the maternal circulation is possible with a properly designed and executed polymerase chain reaction. However, there was considerable variation with respect to when these fetal cells first became detectable during pregnancy. These fetal cells are potentially a valuable source of material for biochemical and genetic studies of the fetuses.

Identification of the histidine residues of hemopexin that coordinate with heme-iron and of a receptor-binding region.

Rabbit hemopexin cDNA was cloned from a rabbit liver lambda gt11 cDNA expression library using a mixture of five monoclonal antibodies raised against rabbit hemopexin, and the entire rabbit hemopexin sequence was determined. The heme-binding domain I of rabbit hemopexin (Smith, A., and Morgan, W. T. (1984) J. Biol. Chem. 259, 12049-12053) contains only 4 histidine residues which are conserved in rabbit, human, rat, and mouse hemopexin. The 2 axial heme-iron coordinating histidine residues, identified by Edman microsequencing and amino acid analyses of chemically modified domain I and isolated fragments of domain I, are the conserved histidine residues at positions 56 and 127 of the mature rabbit protein. The epitope recognized by JEN-14 (a monoclonal antibody which specifically reacts with domain I and blocks the hemopexin-receptor interaction (Morgan, W. T., Muster, P., Tatum, F. M., McConnell, J., Conway, T. P., Hensley, P., and Smith, A. (1988) J. Biol. Chem. 263, 8220-8225) was shown to lie between residues 122 and 142 by Western blotting of protease-digested domain I and transposon-insertion mutants of domain I expressed in a plasmid vector system. The location of this epitope near the heme-binding histidine residue 127 is compatible with a transport mechanism in which the release of heme from hemopexin is accompanied by a concomitant transfer of heme to the hemopexin receptor or the membrane heme-binding protein (Smith, A., and Morgan, W. T. (1985) J. Biol. Chem. 260, 8325-8329).

Lack of mutational alteration in the conserved regions of ZFY and SRY genes of 46,XY females with gonadal dysgenesis.

To further our understanding of the mechanism of action of regulatory and structural genes involved in human sex determination, we have examined three sex-reversed 46,XY females and two of their normal fathers for any mutational alteration in ZFY and SRY genes, using polymerase chain reaction and single-strand conformation polymorphism and by subsequent DNA sequencing. We could not find any mutation in the ZFY and SRY genes of these patients and their fathers. The results seem to suggest that although ZFY and SRY may be required for initiation of testis differentiation and male sex determination, sex-reversed females may predominantly result from alterations in genes either downstream or secondary to ZFY or SRY.

Analysis of peripheral blood of pregnant women for the presence of fetal Y chromosome-specific ZFY gene deoxyribonucleic acid sequences.

Deoxyribonucleic acid sequences of human ZFY (zinc-finger-Y) gene, a Y-chromosome-specific gene and candidate for the testis-determining factor, has been identified by an in vitro enzymatic deoxyribonucleic acid amplification method in peripheral blood specimens of women pregnant with male fetuses. This technique permits detection of ZFY gene deoxyribonucleic acid sequences in as few as a single male cell among 1,000,000 female cells. Maternal blood results were confirmed by amplification of ZFY gene deoxyribonucleic acid sequences in chorionic villus cells and by karyotyping in 33 of 36 pregnant women. There was no false-positive male result, and two of the three blood specimens with false-negative results were obtained from pregnant women at a very early gestational age. With properly designed guidelines, this deoxyribonucleic acid amplification method may be an alternative to determine the fetal sex for those pregnancies at risk for X-linked genetic disorders.

Molecular and genetic analysis of a region of plasmid pCF10 containing positive control genes and structural genes encoding surface proteins involved in pheromone-inducible conjugation in Enterococcus faecalis.

Exposure of Enterococcus faecalis cells carrying the tetracycline resistance plasmid pCF10 to the heptapeptide pheromone cCF10 results in an increase in conjugal transfer frequency by as much as 10(6)-fold. Pheromone-induced donor cells also express at least two plasmid-encoded surface proteins, the 130-kDa Sec 10 protein, which is involved in surface exclusion, and the 150-kDa Asc10 protein, which has been associated with the formation of mating aggregates. Previous subcloning and transposon mutagenesis studies indicated that the adjacent EcoRI c (7.5 kb) and e (4.5 kb) fragments of pCF10 encode the structural genes for these proteins and that the EcoRI c fragment also encodes at least two regulatory genes involved in activation of the expression of the genes encoding Asc10 and Sec10. In this paper, the results of physical and genetic analysis of this region of pCF10, along with the complete DNA sequences of the EcoRI c and e fragments, are reported. The results of the genetic studies indicate the location of the structural genes for the surface proteins and reveal important features of their transcription. In addition, we provide evidence here and in the accompanying paper (S. B. Olmsted, S.-M. Kao, L. J. van Putte, J. C. Gallo, and G. M. Dunny, J. Bacteriol. 173:7665-7672, 1991) for a role of Asc10 in mating aggregate formation. The data also reveal a complex positive control system that acts at distances of at least 3 to 6 kb to activate expression of Asc10. DNA sequence analysis presented here reveals the positions of a number of specific genes, termed prg (pheromone-responsive genes) in this region of pCF10. The genes mapped include prgA (encoding Sec10) and prgB (encoding Asc10), as well as four putative regulatory genes, prgX, -R, -S, and -T. Although the predicted amino acid sequences of Sec10 and Asc10 have some structural features in common with a number of surface proteins of gram-positive cocci, and the Asc10 sequence is highly similar to that of a similar protein encoded by the pheromone-inducible plasmid pAD1 (D. Galli, F. Lottspeich, and R. Wirth, Mol. Microbiol. 4:895-904, 1990), the regulatory genes show relatively little resemblance to any previously sequenced genes from either procaryotes or eucaryotes.

Role of the pheromone-inducible surface protein Asc10 in mating aggregate formation and conjugal transfer of the Enterococcus faecalis plasmid pCF10.

The high transfer frequency of pheromone-inducible conjugative plasmids of Enterococcus faecalis in liquid culture is due in part to the formation of mating aggregates. These aggregates result from the interaction of two surface components, aggregation substance (AS), which is plasmid encoded, and the chromosomally encoded binding substance (BS). In the accompanying paper (S.-M. Kao, S. B. Olmsted, A. S. Viksnins, J.C. Gallo, G. M. Dunny, J. Bacteriol, 173:7650-7664, 1991), the sequence of the prgB gene encoding the AS molecule (Asc10) produced by pheromone-induced cells carrying plasmid pCF10 is presented. Here we report the results of genetic and immunological experiments which define the role of Asc10 in aggregation and plasmid transfer. These data indicate expression of AS on the surface of an E. faecalis cell and its binding to BS expressed on a second cell are required for the formation of a mating pair and the efficient transfer of pCF10 in liquid matings. However, the orientation of the receptors was not critical for transfer; ie., AS expressed on recipient cells could facilitate plasmid transfer via binding to BS on the donor. Our results suggest that additional (as yet unidentified) products are involved in forming the channel that ultimately serves to transfer the DNA, with AS-BS binding serving primarily to generate the initial attachment between cells. The putative prgC gene product, identified by DNA sequencing (data presented in the accompanying paper), could be involved in transfer events occurring subsequent to aggregation.

Intraamniotic detection of Chlamydia trachomatis deoxyribonucleic acid sequences by polymerase chain reaction.

The presence of Chlamydia trachomatis in cervicovaginal cells and amniotic fluid of pregnant women was examined by culture and by polymerase chain reaction deoxyribonucleic acid amplification methods. Chlamydial deoxyribonucleic acid sequences were found in nine of 31 (29.0%) cervicovaginal cell specimens, five of which also were positive by culture method. Amniotic fluid specimens from two of the nine (22.2%) cervicovaginal chlamydial deoxyribonucleic acid-positive women and none from the remaining 22 cervicovaginal chlamydial deoxyribonucleic acid-negative women were found to contain chlamydial deoxyribonucleic acid. The results underscore the significance and frequency of intraamniotic chlamydial infection in women with urogenital chlamydial infections.

Serum hepatitis B virus DNA in hepatitis B virus seropositive and seronegative patients with normal liver function.

The presence of hepatitis type B virus (HBV) DNA in serum specimens from 926 apparently healthy people with normal liver functions was determined by polymerase chain reaction; 41.2% of people with positive results for HBV surface antigen (HBsAg) (94 of 228) and 95.2% of people with positive results for HBV e antigen (HBeAg) (60 of 63) were found to have positive results for serum HBV DNA. On the other hand, serum HBV DNA was found in 11.0% (77 of 698) of HBsAg-negative people and in 13% (69 of 530) of those who had positive results for serum antibodies directed against HBsAg. The results seem to suggest that HBV DNA can be found in a significant portion of apparently healthy people with normal liver function who are either seronegative for HBsAg or seropositive for antibodies directed against HBsAg.

Detection of human cytomegalovirus in cervicovaginal cells by culture, in situ DNA hybridization and DNA amplification methods.

The presence of human cytomegalovirus (HCMV) was tested in 388 cervicovaginal cells specimens obtained from the same number of pregnant women. HCMV was detected in 5.41%, 11.6% and 13.9% of these specimens by conventional culture, in situ DNA hybridization and polymerase chain reaction (PCR) methods, respectively. The sensitivities of detecting HCMV by in situ hybridization and PCR methods were 76.2% and 90.5% and the specificities were 92.1% and 90.5%, respectively, when compared with conventional culture method. The PCR compared favourably with both conventional culture and in situ hybridization methods and it may become a valuable and useful tool for the early and rapid detection of HCMV in clinical specimens.

Endocervical chlamydial deoxyribonucleic acid in infertile women.

The presence of chlamydial deoxyribonucleic acid (DNA) was evaluated by DNA hybridization in endocervical cells of infertile and normal fertile women. Chlamydial DNA was detected in 49 of 186 (26.3%) infertile patients, which is significantly more common than in fertile control individuals (12.5%, or 8 of 64 individuals). Among infertile patients, 49.3% (33 of 67) of those with tubal factors as cause of infertility and 13.4% (16 of 119) of those with nontubal factors were found to contain chlamydial DNA in their endocervical cells. The results show that chlamydial DNA could be found significantly more frequently in endocervical cells of infertile patients with tubal factor than those without tubal factors or in normal controls.

Cloning and expression of genes encoding pheromone-inducible antigens of Enterococcus (Streptococcus) faecalis.

Fragments, generated by restriction enzyme digestion, of the 58-kilobase Enterococcus (Streptococcus) faecalis tetracycline resistance plasmid pCF10 were cloned and introduced into Escherichia coli and E. faecalis to characterize the pheromone-inducible conjugation system encoded by this plasmid. Western blot (immunoblot) analyses revealed that a 130-kilodalton (kDa) antigen, identical to the Tra130 antigen shown previously to be involved in pCF10-mediated pheromone-inducible surface exclusion, was produced by both bacterial hosts carrying the recombinant plasmid pINY1825 (cloned EcoRI C fragment). Both bacterial hosts carrying pINY1825 also produced various amounts of immunologically related 118- to 125-kDa antigens (designated pre-Tra130) that resembled antigens produced by E. faecalis cells carrying pCF10. An additional 150-kDa antigen, Tra150, probably involved in pheromone-induced cellular aggregation, was produced by Escherichia coli and E. faecalis hosts carrying pINY1801 (cloned EcoRI C and E fragments). The coding sequences for the Tra150 and Tra130 antigens were further localized in the TRA region of pCF10 by transposon insertion mutagenesis. Western blot analyses of the recombinant strains, and of strains carrying derivatives of pCF10 or various recombinant plasmids containing Tn5 or Tn917 insertions, suggested that the portion of pCF10 comprising the tra3 through -6 segments (previously defined by Tn917 insertional mutagenesis) contained several genes that are involved in regulating the synthesis of Tra130 and Tra150.