Severe tumor lysis syndrome following splenic irradiation.

A 72-year-old man suffering from non-Hodgkin's lymphoma is described. After failing to respond to chlorambucil-prednisone regimen for three months, he was treated by splenic irradiation (total dose 500 cGY) in 10 consecutive daily doses. Two days after the last irradiation, the patient developed acute tumor lysis syndrome (TLS) with extreme blood levels of uric acid (33.7 mg/dl), phosphorus (13.7 mg/dl), potassium (6.08 mEq/l), and calcium (6.8 mg/dl). It should be remembered that the acute TLS, which usually occurs following chemotherapy, can also be radiation-induced.

Adult onset Still's disease associated with Epstein-Barr virus infection in a 66-year-old woman.

Adult onset Still's disease (AOSD) is a distinct clinical entity which affects predominantly young adults aged 16-35 years. Onset in elderly individuals is exceptional. Several reports have suggested a viral trigger in the pathogenesis of this disease. We describe a 66-year-old woman who fulfilled the proposed diagnostic criteria of AOSD and suffered concurrently from acute Epstein-Barr virus (EBV) infection.

Validation of the 36-item short-form Health Survey (Hebrew version) in the adult population of Israel.

OBJECTIVES: In the past few years, the SF-36 Health Survey has drawn considerable attention from researchers in non-English-speaking countries. This report contributes to the growing body of literature on this instrument by reporting the results of a national study conducted in Israel. The study examined the psychometric properties of the Hebrew translation based on a sample of the adult population of Israel and evaluated the results from a cross-national perspective. METHODS: The sample included 2,030 adults drawn from the Jewish population, aged 45 to 75 years. The SF-36 Health Survey was administered in face-to-face interviews as part of a broader health study. RESULTS: The pattern of correlations among items and the internal consistency scores pointed to high reliability. Confirmatory factor analysis using the Amos 3.61 program supported the hypothesized factorial structure. Specifically, the items clustered around eight health dimensions, as was found in studies in other societies. Clear and statistically significant differences in the SF-36 Health Survey scores were found among age groups and population groups distinguished by the degree of chronic health problems. CONCLUSIONS: Results of the analysis indicate that the instrument provided an appropriate measure of general health status. The findings clearly indicate that the translation into the Hebrew language and the application of the instrument to a culturally heterogeneous population did not diminish the qualities of the instrument. They also point to certain items that might be modified to reduce problems of synonimity and embeddedness.

Primary biliary cirrhosis and systemic lupus erythematosus. A rare association.

Although the co-existence between primary biliary cirrhosis (PBC) and one or more autoimmune diseases is very common, the association with systemic lupus erythematosus (SLE) is believed to be rare. We describe a 37-year-old woman with PBC who developed clinical and serological features of SLE 4 years later. The anti-mitochondrial antibody (AMA) titers fell to undetectable levels during the acute phase of the SLE. At the same time, high titers of antinuclear antibodies (ANA) were detected. Changes in opposite directions in the AMA and ANA titers were also seen during remission of the SLE.

Antimitochondrial antibodies after acute myocardial infarction.

The development of anti-heart mitochondrial antibodies (AHMA) after acute myocardial infarction (AMI) has been previously demonstrated in experimental studies. We performed a prospective study to check the incidence, variation curve and specificity of AHMA and AMI by using two different immunological tests: complement fixation and antihuman globulin consumption. Serial venous blood samples were drawn from the patients as follows: for the first 14 days after the event, once every other day; from 14 to 60 days after the acute event, once a week. The development of AHMA was demonstrated in the sera of 15/35 (45.4%) patients with AMI by complement fixation test using mitochondrial antigen obtained from normal human heart tissue compared to 12/33 (36.3%) by using mitochondrial antigen from the infarcted region. The antibodies exhibited cross-reaction with mitochondrial antigens obtained from human skeletal muscle, but did not react with heterologous heart mitochondrial antigens. According to the results of the antihuman globulin consumption test, the AHMA is immunoglobulin M (IgM). None of the patients developed postmyocardial infarction syndrome.

Pilot study of positron emission tomography in patients with advanced head and neck cancer receiving radiotherapy and chemotherapy.

BACKGROUND: Positron emission tomography (PET) provides a noninvasive modality for evaluating the biochemical processes of normal and pathologic tissue. Preliminary reports of F-18 fluorodeoxyglucose (FDG) PET indicate its potential usefulness in evaluating head and neck tumors. The current study was performed to explore the relationship between changes in tumor FDG metabolism and local control in patients receiving hyperfractionated radiotherapy and concurrent chemotherapy. METHODS: The study group consisted of six patients with locally advanced, nonmetastatic squamous cell carcinoma of the head and neck. FDG studies were performed prior to, during, and 24 months post-therapy. Ratios of tumor to nontumor FDG uptake in regions of interest (ROI) were compared. RESULTS: All pretherapy studies demonstrated a focal hypermetabolic abnormality corresponding to the known tumor. The pretherapy tumor to nontumor FDG ratios declined significantly during therapy (p < 0.05) with a similar continued trend post-therapy (p < 0.07). CONCLUSION: The treatment-induced decrease in tumor hypermetabolism as seen on serial FDG PET parallels the clinical response in squamous carcinoma of the head and neck. Two-year follow-up scans also suggest that continued low tumor to nontumor ratios reflect eradication of local disease. Because of its high cost, a study of larger numbers of patients is necessary to better define the role of PET in the management of head and neck cancer.

Neuroimaging in infantile autism.

Metabolic findings using [18F]fluorodeoxyglucose (FDG) with positron emission tomography (PET) and correlative anatomic findings with computed tomography (CT) or magnetic resonance imaging (MRI) were characterized in 13 children with infantile autism. Four of 13 patients had both an abnormal FDG-PET and an abnormal MRI, whereas seven of 13 patients had both a normal FDG-PET and a normal CT or MRI. Sixteen of a total of 195 brain areas qualitatively examined with FDG-PET had a hypometabolic abnormality on PET. Three of the five abnormal structural imaging studies revealed neuronal migrational anomalies (focal pachygyria). In two of the five patients with anatomic abnormalities, these were noted only after knowledge of the FDG-PET findings. Our experience reveals that anatomic and metabolic abnormalities can be found in children who exhibit autistic behavior. An FDG-PET study may provide evidence of metabolic dysfunction after an initially unremarkable MRI scan because subtle anatomic abnormalities (as those seen with neuronal migrational anomalies) may be found only after knowledge of a regional metabolic abnormality.

Normal brain F-18 FDG-PET and MRI anatomy.

Image registration techniques will become increasingly important in correlative multimodality imaging. In the case of PET, a structural imaging study can be invaluable in correlating structure metabolism relationships. A registered brain atlas of PET and MRI has been developed by the authors that allows clinicians, residents, fellows, and others to refer to a structural abnormality on MRI or metabolic abnormality on PET and correlate it neuro-anatomically.

Serial FDG-PET studies in the prediction of survival in patients with primary brain tumors.

OBJECTIVE: This study examines the changes in tumor [18F]fluoro-2-deoxyglucose (FDG) uptake on serial FDG-PET studies and the ability of serial FDG-PET studies to predict survival in patients with treated and untreated primary brain tumors. MATERIALS AND METHODS: The study population included 20 patients with primary brain tumors. Changes in FDG uptake over time were visually assessed and correlated with clinical course and survival. RESULTS: Although little change in FDG uptake was noted for individual patients, high average FDG uptake (greater than or equal to gray matter) on serial studies was associated with shorter survival. Patients with persistently low FDG uptake (less than gray matter) survived significantly longer than patients with persistently high FDG uptake (p = 0.007). CONCLUSION: Serial evaluation of metabolic activity with PET may provide more accurate prognostic information than a single FDG uptake determination in patients with primary brain tumors.

An interactive, computer-based atlas of neurologic positron emission tomographic studies for use in teaching.

Recent developments in personal computer hardware and software allow the manipulation of radiologic images. We developed an interactive, computer-based atlas of clinical neurologic positron emission tomographic studies for use as an educational resource. A personal computer and multimedia software were used to assemble the clinical case studies. For each clinical case, the user had available the clinical history, positron emission tomographic and correlative anatomic images, study interpretation, discussion, and references. The clinical cases were selected for their educational value, either as a representative example of an abnormality or for their ability to illustrate a common pitfall in positron emission tomographic imaging of the brain.

FDG-PET in differentiating lymphoma from nonmalignant central nervous system lesions in patients with AIDS.

Structural imaging studies such as CT or MRI are not able to accurately differentiate infectious from malignant cerebral lesions in patients with AIDS. We studied 11 individuals with AIDS and central nervous system (CNS) lesions with 18F-fluoro-2-deoxyglucose (FDG) and positron emission tomography (PET). FDG-PET was able to accurately differentiate between a malignant (lymphoma) and nonmalignant etiology for the CNS lesions. Both qualitative visual inspection of the images as well as semiquantitative analysis using count ratios was performed and revealed similar results. FDG-PET may be useful in the management of AIDS patients with CNS lesions since high FDG uptake most likely represents a malignant process which should be biopsied for confirmation rather than treated presumptively as infectious.

Uveitis, a presenting symptom of malignant histiocytosis.

A patient presenting initially with bilateral uveitis was admitted 6 weeks later to the Department of Internal Medicine "A" because of fever, chills, and pancytopenia. Physical examination, ultrasonography and CT scan revealed hepatosplenomegaly only, without lymphadenopathy. A bone marrow trephine biopsy showed areas with a dense infiltrate of abnormal cells, displaying many mitotic figures. Some of the cells resembled better differentiated histiocytes and contained hemosiderin pigment or phagocytosed erythrocytes. Immunohistological tests confirmed the diagnosis of malignant histiocytosis (MH). A survey of the literature revealed two other cases with uveitis and MH.

Peritoneal reaction resulting from iodinated contrast material: comparative study.

A consensus does not exist as to the optimal contrast agent for hysterosalpingography. This study was undertaken to evaluate the early and delayed inflammatory responses of the peritoneal surfaces to various types of iodinated contrast media. Guinea pigs received intraperitoneal injections of lactated Ringer solution, iothalamate meglumine, diatrizoate sodium, ioxilan, or ethiodized oil. The inflammatory response of the peritoneal surfaces was assessed at 1,7, and 30 days. Five animals were studied at each time point for each agent. No animals that received Ringer lactate or iothalamate meglumine had inflammation at any time. Ioxilan produced inflammation in two of five animals at 7 days and no inflammation at 1 or 30 days. Ethiodized oil produced no inflammation at 1 day; however, three animals had inflammation at 7 days, and all five had inflammation at 30 days. The 30-day group showed striking inflammatory response with granulomatous features. The authors recommend the continued use of meglumine-based water-soluble ionic contrast material for hysterosalpingography.

Bilateral multicystic dysplastic kidneys.

High-resolution ultrasound examination of the fetus enables early detection of congenital malformations of the urinary tract. This information is of value in determining fetal prognosis, in deciding the method of delivery, and in alerting the pediatricians to supportive and corrective measures which may need to be taken in the postnatal period. Prenatal diagnosis of bilateral multicystic kidneys was made in a 33-34 week old fetus. A short discussion of this anomaly follows.

Computed axial tomography of brain in neuro-ocular Behçet's syndrome.

The case history of a 34-year-old male with a neuro-ocular Behçet and left sided hemiparesis is reported. On computerized tomography (CT) of the brain using contrast medium a homogeneous enhancement was seen. This conforms with the very few similar reported cases of Behçet's syndrome and is in discordance with the CT findings in cases of cerebral stroke. We conclude, therefore, that the appearance of a homogeneous enhancement on contrast CT can be of diagnostic value in neuro-Behçet.