A controlled trial of intravenous immunoglobulin G in chronic fatigue syndrome.

PURPOSE: Currently, there is no established therapy for chronic fatigue syndrome (CFS), a recently defined illness that has been associated with a variety of immunologic abnormalities. Based on the hypothesis that a chronic viral infection or an immunoregulatory defect is involved in the pathogenesis of CFS, the therapeutic benefit of intravenous immunoglobulin G (IV IgG) was evaluated in a group of patients with CFS. Additionally, serum immunoglobulin concentrations and peripheral blood lymphocyte subset numbers were measured at the outset of the study, and the effect of IV IgG therapy on IgG subclass levels was determined. PATIENTS AND METHODS: Thirty patients with CFS were enrolled in a double-blind, placebo-controlled trial of IV IgG. The treatment regimen consisted of IV IgG (1 g/kg) or intravenous placebo (1% albumin solution) administered every 30 days for 6 months. Participants completed a self-assessment form prior to each of the six treatments, which was used to measure severity of symptoms, functional status, and health perceptions. Patients were also asked to report adverse experiences defined as worsening of symptoms occurring within 48 hours of each treatment. RESULTS: Twenty-eight patients completed the trial. At baseline, all 28 patients complained of moderate to severe fatigue, and measures of social functioning and health perceptions showed marked impairment. Low levels of IgG1 were found in 12 (42.9%), and 18 (64.3%) had low levels of IgG3. At the end of the study, no significant therapeutic benefit could be detected in terms of symptom amelioration or improvement in functional status, despite restoration of IgG1 levels to a normal range. Major adverse experiences were observed in 20% of both the IV IgG and placebo groups. CONCLUSION: The results of this study indicate that IV IgG is unlikely to be of clinical benefit in CFS. In addition to the ongoing need for placebo-controlled trials of candidate therapies for CFS, an expanded research effort is needed to define the etiology and pathogenesis of this disorder.

[Repolarization anomalies in postoperative ECG after aorto-coronary bypass]. / Anomalies de repolarisation de l'ECG post-opératoire des pontages aorto-coronaires.

The authors studied 164 patients admitted in 1994 to their rehabilitation centre less than 5 weeks after a coronary artery bypass graft. They performed an ECG on admission and noted the presence and localization of repolarization abnormalities such as a flat or negative T wave as well as the presence of QRS abnormalities, such as conduction disorders or sequelae of necrosis. The abnormalities were compared with the presence and severity of the pericardial reaction on ultrasonography and in the revascularized territories. Two-thirds of patients presented repolarization abnormalities in the anteroseptoapical (ASA) territory, regardless of the intensity of the pericardial reaction. 88% of patients with no QRS abnormalities (75 patients), had an ASA repolarization abnormality. 80% of patients presenting sequelae of isolated inferior necrosis had normal ASA repolarization. The intensity of the pericardial reaction does not determine the presence of postoperative repolarization abnormalities, but rather "myocardial" abnormalities and especially sequelae of inferior necrosis which "normalize" ASA repolarization in 80% of cases, which raises a doubt about the mechanism of these repolarization abnormalities.

[Systemic cholesterol embolism]. / Les embolies systémiques de cholestérol.

The authors report two cases of cholesterol embolism and review the literature on this subject. Cholesterol crystal emboli are very serious complication of atheroma, generally situated in the aorta and usually in patients in their sixties. The frequency of cholesterol embolism is 20% in autopsy studies in this population. The embolic process accounts for the polymorphic clinical feature. Clinical signs are always delayed in relation to triggering factors. The symptoms can sometimes simulate a systemic disease. Cutaneous signs are present in 40 to 75% of cases. Acute renal failure is present in 30% of cases. Other signs may also be observed: alteration of the general state, fever, neurological disorders, pain of the lower limbs, myalgia, gastrointestinal haemorrhage or perforation, ischaemic colitis, pancreatitis, mesenteric or coronary angina. A triggering factor is revealed in 80% of cases: aortic surgery, retrograde aortic catheterization, fibrinolysis or oral anticoagulant treatment. The prognosis is poor due to the clinical context, the patient's age and the absence of any specific treatment. The short-term mortality is 60 to 80% according to various series. The best treatment is prevention: carefully assess the indication for an endovascular procedure in an atheromatous patient; if necessary, perform transoesophageal ultrasonography to evaluate the risk; whenever possible change the incision in vascular investigations or operative procedures in high-risk patients.

Abdominal abscess due to Cardiobacterium hominis and Clostridium bifermentans.

A case of abdominal abscess and bacteremia due to Cardiobacterium hominis and Clostridium bifermentans was successfully treated with surgical drainage and ampicillin-penicillin. This case represents the rare occurrence of C. hominis infection without apparent endocarditis.

Dual-isotope myocardial imaging: feasibility, advantages and limitations. Preliminary report on 231 consecutive patients.

Two hundred and thirty-one patients underwent dual-isotope myocardial imaging (rest thallium-201 followed by stress technetium-99m sestamibi). The feasibility of the procedure was excellent: camera scheduling flexibility was improved and the duration of the procedure was less than that of a classical stress-redistribution procedure. Interpretation of defects due to image attenuation was facilitated by the different attenuation properties of 201Tl and 99mTc-sestamibi in 11 of 19 patients. 201Tl cross-over on 99mTc was found to be 15% +/- 3% with doses of 201Tl and 99mTc-sestamibi of 3 and 10 mCi, respectively, and 7% +/- 2% with doses of 3 and 20 mCi. This protocol should preferentially be reserved for patients with a history of myocardial infarction and/or a basal left ventricular dysfunction, in whom assessment of myocardial viability is of major interest. Extensive clinical validation of the dual-isotope procedure is required and optimal acquisition and reconstruction parameters should be established.

Antibodies with specificity to native gp120 and neutralization activity against primary human immunodeficiency virus type 1 isolates elicited by immunization with oligomeric gp160.

Current human immunodeficiency virus type 1 (HIV-1) envelope vaccine candidates elicit high antibody binding titers with neutralizing activity against T-cell line-adapted but not primary HIV-1 isolates. Serum antibodies from these human vaccine recipients were also found to be preferentially directed to linear epitopes within gp120 that are poorly exposed on native gp120. Systemic immunization of rabbits with an affinity-purified oligomeric gp160 protein formulated with either Alhydrogel or monophosphoryl lipid A-containing adjuvants resulted in the induction of high-titered serum antibodies that preferentially bound epitopes exposed on native forms of gp120 and gp160, recognized a restricted number of linear epitopes, efficiently bound heterologous strains of monomeric gp120 and cell surface-expressed oligomeric gp120/gp41, and neutralized several strains of T-cell line-adapted HIV-1. Additionally, those immune sera with the highest oligomeric gp160 antibody binding titers had neutralizing activity against some primary HIV-1 isolates, using phytohemagglutinin-stimulated peripheral blood mononuclear cell targets. Induction of an antibody response preferentially reactive with natively folded gp120/gp160 was dependent on the tertiary structure of the HIV-1 envelope immunogen as well as its adjuvant formulation, route of administration, and number of immunizations administered. These studies demonstrate the capacity of a soluble HIV-1 envelope glycoprotein vaccine to elicit an antibody response capable of neutralizing primary HIV-1 isolates.

HTLV-III infection among health care workers. Association with needle-stick injuries.

Health care workers are caring for an increasing number of persons infected with human T-cell lymphotropic virus type III (HTLV-III), the primary etiologic agent of the acquired immunodeficiency syndrome (AIDS). We studied 361 health care and clinical laboratory personnel from institutions in several metropolitan areas with both high and moderate levels of HTLV-III infection among high-risk group members to evaluate routes of exposure to and seropositivity for HTLV-III. Protection of the privacy of subjects and prospective determination of risk factors were integral components of the study design. Six (26%) of 23 health care workers with recognized risk factors for AIDS had HTLV-III antibodies. Thirty-nine (14%) of 278 workers at one institution as well as a total of five workers from other institutions reported possible percutaneous exposure to HTLV-III, usually injuries with needles that had been used on AIDS patients. There were three HTLV-III seropositive subjects who reported possible parenteral exposure to HTLV-III but no recognized AIDS risk factors. One was a symptomatic female, subject A, and her apparent sources of HTLV-III exposure were two puncture wounds, without injection of blood, made with needles used on AIDS patients. Human T-cell lymphotropic virus type III was cultured from her asymptomatic, seronegative long-term sexual partner, apparently representing female-to-male transmission. For the two other seropositive workers (subjects B and C) with nosocomial parenteral exposure, we could not rule out heterosexual transmission as a possible source of HTLV-III exposure. These latter two cases as well as the identification of seropositive health care providers from known risk groups point to the need for thorough case investigation to identify routes of exposure in health care workers. The risk of nosocomial HTLV-III transmission appears to be low and related to percutaneous exposure. Medical personnel should be trained systematically in the proper techniques and handling of instruments for phlebotomy and similar procedures to decrease occupational exposure to HTLV-III.