High incidence of occult thyroid disease among general medical ward patients.

The objective of this study was to prospectively determine the efficacy of the results of routine testing of thyroid functions in patients admitted to a general medical ward. Blood for thyroid function tests was drawn on admission as part of the laboratory screening panel from 270 consecutive patients. Fifty-one were excluded due to recognition of thyroid-related problems by the clinical staff. 138 patients (63%) had normal free thyroxin (FT4) levels, one patient had hyperthyroidism, 15 patients (6.8%) had laboratory primary hypothyroidism and 65 patients (29.6%) had equivocal results (FT4 < 0.9 ng/dL and TSH < 5.0 mmu/L). In eight out of 31 patients in the latter group, the thyroid releasing hormone (TRH) test revealed primary or secondary hypothyroidism. A total of 55 patients (25.1%) expired within one year. The mortality rate was significantly higher among the low FT4 patients (p < 0.01), and was independent of age and sex. We conclude that inclusion of FT4 in a laboratory screening panel will reveal a large patient population with abnormal results. However, establishing the diagnosis requires additional tests. Therefore, screening for occult hypothyroidism among a select population, not the acutely sick, populations may be more efficient.

Fatal Shigella sepsis in a neutropenic patient.

Bacteremia during infection with Shigella is relatively rare and usually self-limited. Bacteremia during shigellosis bearing a high fatality rate has been reported in young infants and in persons with malnutrition or with the acquired immunodeficiency syndrome. We report a case of Shigella sonnei septicemia in a severely neutropenic patient who had fever, abdominal pain, diarrhea, malnutrition, and dehydration. She died after five days despite intensive care. We emphasize that Shigella should be considered among the possible pathogens causing sepsis in neutropenic patients.

Differentiation between major and milder acute mental stress by means of the leukocyte adhesiveness/aggregation test.

Following previous observations that the adhesive state of white blood cells in the peripheral blood increases during stress, we examined 645 volunteers in various conditions of anticipatory anxiety. The volunteer subjects included 465 controls in whom stress was related solely to impending venipuncture, 149 persons under moderate stress (students before delivering a graded lecture, patients before dental treatment, etc), as well as 31 individuals under major stress (eg, before induction of anesthesia in the operating room). The respective values of aggregated leukocytes in the peripheral blood were 5.2 +/- 3.8, 6 +/- 4.2, and 19.3 +/- 9.3% of aggregated cells, with a significant difference (p < .0001) between the third and the other two groups. In both discriminant analysis and multiple regression, the leukocyte adhesiveness/aggregation test (LAAT) was shown to be superior to the white blood cell count for the detection of major stress. The LAAT had a sensitivity of 0.8, compared with only 0.35 for leukocyte count for that purpose. We concluded that the LAAT could be a powerful tool for the diagnosis of major acute mental stress and for discrimination between conditions causing major stress and those conditions that are less stressful.

Sarcoidosis as the initial manifestation of Takayasu's arteritis.

Takayasu's arteritis is a chronic inflammatory arteriopathy of unknown cause. The pulseless phase of Takayasu's arteritis is preceded by a period of "prepulseless disease" when the patients suffer from systematic symptoms without obvious evidence of obstruction of larger arteries. Herein we report a unique case of Takayasu's arteritis presenting as sarcoidosis manifested by restrictive lung disease, hilar adenopathy and non-caseating granulomas of the skin. We are aware of only one report in which non-caseating skin granulomas were evident at the prepulseless phase of Takayasu's arteritis. However, in our patient the clinical picture was typical of sarcoidosis. Increased awareness of this possibility will lead to more frequent skin biopsies in patients with Takayasu's arteritis and nodular skin lesions, which may increase the number of reported cases with this combination.

Treatment of systemic lupus erythematosus by prolonged administration of high dose intravenous immunoglobulin: report of 2 cases.

Two patients with life threatening manifestations of systemic lupus erythematosus (SLE), unresponsive to corticosteroid and immunosuppressive therapy, were treated with high dose intravenous immunoglobulin (IVIG). Following IVIG therapy, lupus pneumonitis and encephalitis in the first patient, and lupus nephritis in the second patient, resolved. Continuous treatment with IVIG, every 4 weeks for up to 20 months induced a prolonged clinical and laboratory remission. Treatment with cytotoxic agents was stopped, and the dosage of corticosteroids lowered. Exacerbation of lupus nephritis occurred in the second patient after 10 months of IVIG therapy. We suggest that prolonged use of high dose IVIG may be a useful therapy for acute exacerbations of SLE and for inducing prolonged remissions.

Increased leukocyte adhesiveness/aggregation and tissue leukostasis following surgical trauma.

The purpose of the present study was to document the increased leukocyte adhesiveness/aggregation (LAA) and tissue leukostasis that follow surgical trauma. We found that following major abdominal surgery, the percentage of aggregated leukocytes in the peripheral blood increased from 8.6 +/- 7 to 21.7 +/- 11.5 (p < 0.001), while the respective values for patients undergoing minor surgery were 3.7 +/- 2.4 and 19.7 +/- 7.6% (p < 0.001). The state of LAA was also determined in eight dogs after partial collectomy and four controls. A clear increment in the degree of tissue leukostasis (especially in the spleen, liver and lungs) was noted in the operated as compared to the control animals. In addition, a significant correlation was found between the state of LAA, determined in the venous (p = 0.0004) and arterial (p = 0.002) blood of these animals and the degree of tissue leukostasis. We conclude that a state of increased LAA in the peripheral blood is induced by surgical trauma and that this increased LAA correlates with tissue leukostasis.

Erythromycin base-induced rash and liver function disturbances.

OBJECTIVE: To report a case of erythromycin base-induced rash and liver function disturbances. CASE SUMMARY: A patient with erythema nodosum and high antistreptolysin-O titers was treated with erythromycin on the assumption that occult streptococcal infection was the cause of the erythema nodosum. Forty-eight hours after the initiation of therapy the patient developed fever, severe generalized rash, pruritus, and cholestatic and hepatocellular liver function disturbances. Extensive evaluation to determine the cause of liver function disturbances was unrevealing. Marked improvement was noticed within days after cessation of erythromycin. DISCUSSION: Case reports in the literature on the adverse effects of erythromycin and its derivatives were reviewed. The possible immunologic mechanism involved is postulated. CONCLUSIONS: Erythromycin base must be added to the list of erythromycin derivatives that can cause rash and liver function disturbances. The concomitant appearance of fever, rash, jaundice, and liver function disturbances raises the possibility of hypersensitivity as the mechanism for the liver disturbances.

Yersinia enterocolitica endocarditis on a prosthetic valve.

Yersinia entercolitica endocarditis has rarely been described before. This is the first report of prosthetic valve Yersinia enterocolitis endocarditis, complicated by infected brain embolization. The patient, however, completely recovered after 6 weeks of combined therapy with ceftriaxone and gentamicin.

Lupus anticoagulant: correlation with magnetic resonance imaging of brain lesions.

Brain magnetic resonance imaging (MRI) was performed in 21 patients with systemic lupus erythematosus (SLE) with and without lupus anticoagulant (LAC), one lupus-like patient and 5 patients with primary antiphospholipid antibody syndrome. Thirteen patients had white matter focal brain lesions on MRI, 10 of whom had LAC (p = 0.03). We found no correlation between these lesions and neurologic manifestations, nor any clinical or serologic indices of activity of SLE. Our MRI lesions were similar to those described in multiple sclerosis and may indicate a similar pathologic process.

The state of leukocyte adhesiveness/aggregation in the peripheral blood is more sensitive than the white blood cell count for the detection of acute mental stress.

We determined the state of the leukocyte adhesiveness/aggregation in the peripheral blood by using a simple slide test and found it to be more sensitive than the white blood cell count for the detection of acute mental stress. Included were 71 controls, 64 young athletes examined just before their exercise, 14 volunteers who were examined 10-20 min before engagement in rappelling while an additional group of 20 were examined just before the act as they were facing an abyss from the top of a cliff. The state of leukocyte adhesiveness/aggregation correlated significantly (p less than 0.0005) only with the increasing strain assumed to occur from the first to the fourth group. The state of leukocyte adhesiveness/aggregation was 3.3 x more sensitive than white blood cell count in both rappelling groups and 5 x more sensitive than white blood cell count when evaluated in those examined at the last minute. We concluded that the state of leukocyte adhesiveness/aggregation is a reliable marker of acute mental stress.

Corynebacterium CDC group A-4 native valve endocarditis.

A patient with endocarditis caused by Corynebacterium CDC Group A-4 is described. This is the first case in the literature of endocarditis caused by this bacteria, and is unique in that the patient was immune competent and the infection occurred on a native valve. This case illustrates that corynebacteria cannot be considered a contaminant and that the exact pathogen should be identified.

Urinary retention associated with ipratropium bromide.

A 69-year-old man was hospitalized for exacerbation of chronic obstructive lung disease. Treatment with nebulized ipratropium bromide resulted in urinary retention that resolved once the drug was discontinued. Urinary retention is a rare complication of ipratropium bromide. Because all of the cases described in the literature occur in elderly men with prostate hypertrophy, the drug should be used cautiously in this group of patients.

Possible role for a plasma factor in the induction and/or maintenance of the state of leukocyte adhesiveness/aggregation in the peripheral blood. A study of mothers and their newborns.

The adhesive property of white blood cells is essential for a normal immune response. We examined the state of leukocyte adhesiveness/aggregation (LAA) in the peripheral blood of 31 mothers and their newborns by means of a direct slide test and found it to differ significantly, the respective per cents of aggregated leukocytes found in the peripheral blood being 15 +/- 6.4 and 5 +/- 3.3 (mean +/- SD). However, the particle concentration of white blood cells in the peripheral blood did not differ significantly (14.2 +/- 4.4 and 13.6 +/- x 10(9) l-1). By incubating a mother's plasma with her newborn's whole blood we could induce a significant (p less than 0.0001) increment in the state of LAA. We conclude that deficiency of a plasma factor that does not cross the placenta is responsible for the low LAA in the newborn's peripheral blood.

Cerebral infarct associated with lupus anticoagulant in an adolescent girl: a case report with review of the literature.

A 15-year-old girl with right-sided cerebral infarct in association with lupus anticoagulant is described. The literature on the primary antiphospholipid syndrome and its neurological complications is reviewed.

Native valve Staphylococcus epidermidis endocarditis: report of seven cases and review of the literature.

This report describes seven patients from three university hospitals whose native valve infective endocarditis was caused by Staphylococcus epidermidis. The literature on endocarditis caused by S. epidermidis is also reviewed and the clinical features of patients with native valve endocarditis due to this organism are compared with those of patients from a general series of infective endocarditis cases. Compared with infective endocarditis caused by other organisms, S. epidermidis endocarditis tends to occur more frequently in male patients. Patients with S. epidermidis endocarditis exhibit fewer embolic complications and skin manifestations. The frequency of congestive heart failure is lower in this group. The relative indolent course and apparent rarity of native valve S. epidermidis endocarditis necessitate a high index of suspicion for early diagnosis.

Hemophagocytosis by small cell lung carcinoma.

A 60-year-old woman with disseminated small cell carcinoma of the lung and hemophagocytosis by the metastatic cells in the bone marrow is presented. It is the first clinicopathologic report on phagocytosis of erythrocytes by lung tumor cells in concordance with a recently described evidence of a macrophage origin of small cell carcinoma of the lung.

Detection of aggregated leukocytes in the circulating pool during stress-demargination is not necessarily a result of decreased leukocyte adhesiveness.

Leukocyte endothelial interactions are essential for a normal immune response. It is known that this response is influenced by stress and that the latter induces demargination. We examined the question of whether stress demargination results from a decreased state of leukocyte adhesiveness. Included were various volunteers and patients under different degrees of stress. 66 young athletes before beginning their daily exercises, 67 middle-aged healthy volunteers, 25 patients before ergometry for evaluation of chest pain, 75 patients who were referred to the emergency room with chest pain without ischemia/infarction, 78 patients with ischemia/infarction, 65 patients with minor trauma, 25 with a fracture and 12 with polytrauma. The leukocyte adhesiveness/aggregation (LAA) values were measured with a direct slide test. The respective LAA values were 7.4 +/- 4.7, 6.3 +/- 4.4, 5.8 +/- 3.6, 5.2 +/- 3.5, 10.8 +/- 8.5, 9.1 +/- 5.8, 12.2 +/- 6.6 and 19 +/- 12.6% of aggregated leukocytes. We conclude that an increase in aggregated white blood cells can be detected in the circulating pool during major stress. It is therefore suggested that stress demargination is not necessarily a result of diminished leukocyte adhesiveness.

Heterotypic leukocyte aggregation in the peripheral blood of patients with leukemia, inflammation and stress.

This study deals with the question of whether the aggregates of leukocytes in the peripheral blood are homo- or heterotypic. One hundred-fifty individuals with leukemia, inflammation, and physical and mental stress, were examined. It was found that the various cell populations of the peripheral blood are represented in the aggregates and that aggregates are generally heterotypic. Normal and malignant leukocytes were noted in aggregates of patients with leukemia, suggesting that adhesive mechanisms are similar for both normal and malignant leukocytes. This was also supported in two animal models, one with leukocytosis of normal cells and the other with leukocytosis of leukemic cells, in which the state of leukocyte adhesiveness/aggregation in the peripheral blood correlated with tissue leukostasis. The possibility exists that "non specific stickers", present in the peripheral blood, promote interactions between the white blood cells, normal and malignant, and between these cells and the endothelium.

Systemic sclerosis and chronic lymphocytic leukaemia.

The association between the CREST (calcinosis, Raynaud phenomena, oesophageal hypomotility, sclerodactyly and telangiectasia, variant of systemic sclerosis and chronic lymphocytic leukaemia is described in three patients. The present description raises the possibility that the association of chronic lymphocytic leukaemia and systemic sclerosis is non-random.