Systemic lupus erythematosus, eosinophilia and Löffler's endocarditis. An unusual association.

A 24-yr-old male, known since the age of 11 to have a nonerosive arthritis and later diagnosed as having systemic lupus erythematosus (SLE), developed subacute heart failure with diffuse lung infiltrates and died suddenly after having presented a moderate hypereosinophilia for 6 months for which no other causes besides the SLE were found. A post mortem examination revealed Löffler's endocarditis (endocarditis parietalis fibroplastica) with acute pulmonary capillaritis. This represents Löffler's endocarditis in the setting of SLE. To the best of the authors' knowledge, this association has not been reported before.

Second primary lung cancer in Flanders: frequency, clinical presentation, treatment and prognosis.

Patient and tumour characteristics of 23 patients presenting with a second primary lung cancer were analysed and compared with 534 patients with radically resected stage 1 non-small cell lung cancer (NSCLC). None of these characteristics is associated with a higher occurrence rate for second primary lung cancer. Prognosis in the latter patients is significantly worse than after resection of a 'solitary' NSCLC: the median survival time (MST) after resection of the first tumour is 50 months; after diagnosis of the second tumour only 14 months. Surgically retreated patients have a prognosis that is similar to that after resection of a 'solitary' NSCLC. No separate independent prognostic factors responsible for this survival difference could be isolated. Squamous histology and central location are associated with a longer recurrence free survival time. We conclude that the occurrence of a second primary lung cancer can not be predicted based on patient or tumour characteristics and that only surgical retreatment offers a chance of long survival in these patients.

Surgical treatment of small cell lung cancer.

From 1970 till 1989, 30 patients underwent surgical resection for small cell lung cancer (SCLC). The 5-year survival in stage I patients was 31%, in stage II 17% and in stage III the projected 5-year survival was 9%. Among N2 patients there were only 25% survivors after 1 year and none after 2 years. The first group of 15 patients (1970-1979) received no adjuvant chemotherapy in contrast to the second group of 15 patients (1980-1989). The overall 5-year survival for the first group was 13% and the estimated 5-year survival for the second group was 27%. In stage I SCLC, the 5-year survival was 12% and 60%, respectively. These results confirm that surgery may lead to long-term survival in stage I and possibly stage II SCLC, with better prognosis in stage I when adjuvant chemotherapy is added.

[Control of Trypanosoma gambiense trypanosomiasis. Evaluation of a strategy based on the treatment of serologically suspected cases with a single dose of diminazene]. / Contrôle de la trypanosomiase à T. b. gambiense. Evaluation d'une strategie basée sur le traitement des suspects sérologiques par une dose unique de diminazène.

A novel method for the control of T.b. gambiense trypanosomiasis was evaluated in an endemic focus of Zaïre where a high incidence had persisted despite massive participation in active case-finding surveys based on lymph node puncture. All inhabitants of 3 villages were examined with a card agglutination serological test (CATT), and parasitological examinations were performed on those who were CATT+. Individuals in whom we detected trypanosomes were treated as usual. A lumbar puncture was carried out on CATT+/parasitology- subjects; those whose cerebrospinal fluid showed more than 3 white blood cell (WBC) per mm3 were treated with a full course of melarsoprol while those with a CSF WBC count between 1 and 3 per mm3 were given a single injection of diminazene (7 mg/kg). Three such surveys were performed, with a 6-month interval, during which 282 "serological suspects" received diminazene, 39 "clinical cases" were given melarsoprol and 82 "parasitological cases" were treated according to standard protocols. The annual incidence of trypanosomiasis decreased rapidly from 10.4-41.1/1.000 inhabitants (mean: 17.6/1.000) during the 10 years before the intervention to 1.1-2.6/1.000 (mean: 1.7/1.000) in the 3 years following the intervention. No major adverse effect was seen with diminazene. Among the 282 serological suspects, an elevated CSF WBC count was later documented in 12 individuals, who were all cured with melarsoprol. The incidence increased 5 years after the intervention (7.1/1.000 in 1992), which may have been avoided had we carried out similar interventions in adjacent foci.

Intrathoracic ganglioneuroma: case report.

Ganglioneuromas are rare, benign neoplasms, arising from the sympathetic nervous system. The posterior mediastinum is the most common location of this neurogenic tumour. We present this case because of the problem of its diagnosis. Our patient had in fact been under observation for about twenty years. The size of the tumour caused a restriction of the pulmonary function.

Predictive value of bronchoalveolar lavage in pulmonary sarcoidosis.

We investigated whether analysis of cellular composition (including lymphocyte subsets) in bronchoalveolar lavage (BAL) fluid at the start of follow-up in patients with untreated sarcoidosis has any predictive value for further evolution of the disease. The outcome was evaluated by the chest roentgenograms, the lung volumes, and the single breath diffusing capacity for CO (DCO) after 22 to 36 months. In contrast to the general belief, patients who improved radiologically had a significantly higher T4 cell count (as percentage of BAL lymphocytes) (p less than 0.02) and a higher T4-T8 ratio in the initial BAL sample (9.3 vs 3.2; p less than 0.05) than those whose chest roentgenogram showed deterioration or remained unchanged. Total cell count and the percentage of lymphocytes in BAL fluid were not different between both groups. The change in DCO at the end of the follow-up period correlated positively with the baseline BAL T4 cells (Rs = 0.44; p less than 0.05) and with the BAL T4-T8 ratio (Rs = 0.51; p less than 0.03) and negatively with the baseline BAL T8 cells (Rs = -0.48; p less than 0.04). In only three patients progression of the disease necessitated steroid therapy, and they all had a low to normal T4-T8 ratio in the initial BAL sample. Bronchoalveolar lavage was repeated at least once in ten patients. Improvement of the chest roentgenograms in these patients was accompanied by a decrease of the BAL T4 cell count (as percentage of lymphocytes) and of the T4-T8 ratio. We conclude that a high lymphocyte count, a high T4 cell count (as percentage of lymphocytes), and a high T4-T8 ratio in BAL fluid reflect an intense alveolitis at the time of the procedure, but they are not indicators of poor prognosis on which therapeutic decisions can be based.

[Pulmonary pathology due to cobalt and hard metals]. / La pathologie pulmonaire due au cobalt et aux métaux durs.

For forty years, cases of interstitial pneumonia and bronchial asthma have been described in hard metal workers (i.e., alloys of tungsten carbide and cobalt). Recently we have reported comparable pulmonary lesions in workers in the diamond industry who were exposed to cobalt unassociated with tungsten carbide. The exposure came from the diamond cobalt discs used for polishing diamonds, which had as the hard element microdiamonds, cemented in an alloy of pure cobalt. The hard metals on the other hand consisted of cobalt and tungsten carbide. Forty-seven diamond cutters (i.e., nearly 1% of those exposed) presented with broncho-pulmonary pathology due to cobalt. Nineteen had a fibrosing alveolitis, sometimes documented by a pulmonary biopsy and more often by a broncho-alveolar lavage which revealed characteristic multinucleated giant cells. Thirteen had occupational asthma, often proved by specific inhalation provocation tests to cobalt or by lung function measurements at the place of work. Two patients had mixed forms and in thirteen a probable diagnosis was suggested. The pathogenesis of cobalt might be explained by cytotoxic action such as has been demonstrated in animal experiments. Either results suggest a sensitising or allergic action. Tungsten carbide does not produce pulmonary lesions but its association with cobalt intensifies the effects of the latter.

Intestinal nodular lymphoid hyperplasia in patients with common variable immunodeficiency: local accumulation of B and CD8(+) lymphocytes.

Common variable immunodeficiency (CVI) with hypogammaglobulinemia is often complicated by nodular lymphoid hyperplasia of the intestine. In this study the lymphoid constituents of intestinal nodular hyperplasia of five CVI patients were characterized with monoclonal antibodies. Few CD4(+) but abundant CD8(+) T lymphocytes were found around the follicles. The follicles were populated mainly by B cells expressing surface IgM. A few cells in the lamina propria expressed Leu7. No intracytoplasmic immunoglobulin-containing plasma cells were seen. Peyer's patches in gut biopsies from controls were also composed of follicles with B lymphocytes. A ring of T lymphocytes surrounded the follicles. CD4(+) helper cells largely outnumbered CD8(+) cells in this ring. Moreover, plasma cells were present in the lamina propria and the mixed cell zone covering the follicles. In peripheral blood of the patients, B cells were present in normal proportions but they could not be induced to produce IgG in vitro by T cell-dependent (pokeweed mitogen) or T cell-independent (Staphylococcus aureus Cowan I) mitogens. In two of the patients, IgM production could be induced in vitro. Peripheral blood T cells were predominantly CD8(+) in three of the five patients, and in these same patients an increase in suppressor-cell activity of peripheral blood T cells on immunoglobulin production was observed. The data demonstrate a block in B-cell differentiation in the gut and in peripheral blood. Whether the local increase in CD8(+) cells in the nodular lymphoid hyperplasia is a primary event or is secondary to chronic immune stimulation and whether it contributes to local inhibition of B-cell differentiation remain to be investigated.

Influence of common cold and of parenteral administration of influenza virus antigens on bronchoalveolar lavage cells.

We investigated in a pilot study on healthy young subjects whether a common cold or a vaccination with influenza virus antigens within 10 days influenced the number and subsets of inflammatory cells in the bronchoalveolar lavage (BAL) fluid. The total number of BAL-cells was about doubled in the common cold group, yet no consistent changes in overall cell distribution was found. Among BAL-lymphocytes the ratio of helper-inducer over suppressor-cytotoxic lymphocytes (THI/TCS) tended to be increased in both groups, due to a lower percentage of TCS-cells, which was significant in the vaccination group only. In the blood, on the contrary, the THI/TCS ratio was significantly decreased in both groups due to a drop in THI-cells; in addition, the proportions of E-Rosette (+) T-cells and of activated (Ia+) T-cells were slightly increased. In conclusion, only minor changes in inflammatory BAL-cells were observed, which, however, may interfere with the effects of other diseases.

Cobalt-induced bronchial asthma in diamond polishers.

Three diamond workers had occupational asthma attributed to the inhalation of cobalt powder. The exposure originated from high speed polishing disks with an abrasive consisting of microdiamonds cemented in extra fine cobalt not alloyed to tungsten carbide. The bronchoconstriction progressed towards the end of working-days; it was especially pronounced in the absence of an adequate exhaust ventilation; and it could be accompanied by rhinitis and chest tightness. Cobalt inhalation challenge tests were positive in all three patients, and exposure to cobalt temporarily increased nonspecific hyperreactivity.

Cobalt lung in diamond polishers.

Five diamond polishers with interstitial lung disease attributed to cobalt not alloyed to carbides of hard metals are described. The exposure originated from high-speed grinding tools with a polishing surface of microdiamonds cemented in very fine cobalt. Mineralogic analysis of lung tissue, lavage fluid, filtered air, and exhaust dust in the work environment revealed cobalt as the only toxic agent. Complaints consisted of work-related rhinitis, cough, chest tightness, dyspnea, anorexia, and weight loss, and were intensified in the absence of an adequate exhaust ventilation. Three subjects were in a rather subacute stage, as documented by open lung biopsy in 2 of them, and had a severe restrictive defect and markedly decreased diffusing capacity. Two patients presented a more chronic histologic pattern and had a less decreased diffusing capacity. Open lung biopsies showed in these 4 a fibrosing alveolitis, mainly of the centrilobular zones. In the former 2 patients, subacute lesions consisting of a mural mononuclear cell infiltrate, marked intra-alveolar desquamation, and multinucleated giant cells were found, whereas in the latter 2, centrilobular fibrosis with some microcyst formation was also already seen. Multiple multinucleated giant cells were present in the bronchoalveolar lavage fluid. Interruption of the exposure, with or without corticotherapy, caused a rapid regression of the complaints and a partial improvement of lung function.

Alveolar T-cell subsets in pulmonary sarcoidosis. Correlation with disease activity and effect of steroid treatment.

Alveolar lymphocytes, obtained by bronchoalveolar lavage in 35 patients with sarcoidosis, were analyzed with monoclonal antibodies to lymphocyte subsets. Untreated patients had significantly higher percentages of Leu 3a (+) T helper-inducer cells (THI) and significantly lower Leu 2a (+) T cytotoxic-suppressor cells (TCS) within the alveolar lymphocyte population than did normal control subjects (p less than 0.002). The mean ratio of alveolar THI to TCS cells was 6.20 +/- 3.76 versus 1.44 +/- 0.54 in control subjects (p less than 0.002). Untreated patients had a percentual enrichment of THI cells among alveolar lymphocytes relative to blood (p less than 0.0002), whereas TCS cells in percent of lymphocytes were lower in alveolar lavage fluid than in blood (p less than 0.002). These shifts were not observed in the control subjects. Patients with high-intensity alveolitis (i.e., T cells constituted 28% or more of alveolar inflammatory cells) had significantly greater proportions of THI cells among alveolar lymphocytes than did those with low-intensity alveolitis (p less than 0.01). This percent of alveolar THI cells correlated positively with the number of lymphocytes and T cells in percent of alveolar cells (p less than 0.03), which both are indexes of disease activity. In untreated patients who were lavaged at least twice, a decrease in the THI/TCS ratio was found to accompany or precede radiologic and clinical improvement, but the initial THI/TCS ratio was not predictive of further evolution. Steroid treatment decreased the THI/TCS ratio with a marked increase in the proportion of TCS cells. These changes were independent of an effect on the number of alveolar lymphocytes.(ABSTRACT TRUNCATED AT 250 WORDS)