Stress fracture of the ulna associated with bisphosphonate therapy and use of walking aid.

We report a case of a stress fracture of the ulna secondary to long-term bisphosphonate therapy and walking cane. Physicians need to have a high index of suspicion of stress fractures occurring in patients complaining of chronic upper limb pain if they are on bisphosphonate therapy and are using walking aids. Stress fractures of the upper extremities are rare and are usually associated with athletes; however, a few recent case reports have shown an association between stress fractures of the upper extremities and the use of walking aids. The association between increased incidence of upper extremity stress fractures and the use of both bisphosphonates and walking aids in patients has not been well studied, with only one previously reported case. Here, we report a case of a complete stress fracture of the ulna in a 77-year-old female, premorbidly ambulant with walking cane, on long-term bisphosphonates without any pre-existing medical conditions which could result in secondary causes of bone loss. Investigations did not reveal any causes of pathological fracture. This fracture is attributed to the use of long-term bisphosphonate therapy in conjunction with the use of a walking cane. This case highlights the importance of entertaining the possibility of such fractures occurring in any patient who is on bisphosphonate therapy presenting with stress fractures of the upper extremity.

Incidence and clinical significance of protein-bound vitamin B12 malabsorption.

Patient records from January 1975 to December 1984 were analysed to assess the possible incidence of protein-bound vitamin B12 malabsorption. This condition is characterised by a low serum vitamin B12 level and a normal Schilling test but impaired absorption of vitamin B12 bound to protein. We found that 48 (25%) patients with a low serum cobalamin level unexplained by other causes had a normal Schilling test. Megaloblastic haemopoiesis was found in 25 of these. From this group, all 10 patients who had a test of protein-bound vitamin B12 absorption showed impaired absorption. Protein-bound vitamin B12 malabsorption may represent an early phase of pernicious anaemia when hypochlorhydria precedes intrinsic factor deficiency and should be tested for when the serum vitamin B12 level is decreased and the Schilling test is normal.

Whipple's disease in an HLA-B27 positive female.

The first reported case of Whipple's disease in a female who was HLA-B27 positive and had asymptomatic sacroiliitis is discussed. She presented great difficulty in diagnosis as she had multi-system involvement without diarrhea. This case supports the hypothesis that Whipple's disease is a disorder related to HLA-B27.

Splenectomy for massive splenomegaly.

The technique, and short and long term results, of splenectomy for massive splenomegaly are presented. The latter was defined as a spleen weighing in excess of 1.5 kg. Thirty-five of the 38 patients had a serious haematological disorder as the indication for the operation, usually non-Hodgkin's lymphoma or myelofibrosis. All operations were carried out through abdominal incisions. Accessible splenic attachments were divided, and the splenic artery was ligated in continuity, prior to posterior mobilization. Two patients (5.3%) died as a result of the operation, both deaths being due to sepsis. Septic and thrombo-embolic complications were common, and occurred both early and late after the operation. Overall, eight of the 12 deaths during the first postoperative year were due to the primary disease, whereas all of the five deaths after that time were due to causes other than the primary disease. Twenty-four patients lived at least 1 year, and 10 patients are alive for more than 5 years.

Qualitative platelet defect in a case of heparin-induced thrombocytopenia.

A qualitative platelet defect was demonstrated in a patient with heparin-induced thrombocytopenia. His platelets showed impaired aggregation to collagen and arachidonate and absent second wave aggregation to adenosine diphosphate and epinephrine but normal response to ristocetin. These aggregation abnormalities were similar to those reported in idiopathic thrombocytopenia and systemic lupus erythematosus. This platelet function defect may contribute to haemorrhagic complications which appear to be common in heparin-induced thrombocytopenia.

Heparin-induced thrombocytopenia: effect of heparin platelet antibody on platelets.

The plasma of two patients with heparin-induced thrombocytopenia has been shown to cause platelet aggregation in the presence of heparin. The platelet aggregating factor was isolated in the IgG reaction of the patients' sera suggesting that it was an antibody. This heparin anti-platelet antibody (HAP-Ab) induced platelet aggregation and release but did not cause platelet lysis, although it fixed complement. Platelet aggregation was inhibited by EDTA and by inactivation of complement. There was a significant production of malondialdehyde (MDA) and thromboxane B2 (TXB2) implying a role of the prostaglandin synthesis pathway in HAP-Ab induced aggregation. ADP-release also appeared to be involved as apyrase blocked aggregation while hirudin, a thrombin inhibitor, had no effect. The thrombotic complications that have recently been reported in patients with heparin-induced thrombocytopenia may be explained by some effects of HAP-Ab on platelets, namely: the antibody mediated platelet factor 3 release, prostaglandin endoperoxides and thromboxane A2 (TXA2) production and platelet aggregation in vivo. These HAP-Ab mediated effects could be inhibited by anti-platelet drugs such as aspirin, indomethacin and dipyridamole and thus may have therapeutic implications.

The Lewis system and secretor status in autoimmune hemolytic anemia complicating infectious mononucleosis.

Two patients with acute infectious mononucleosis and associated immune hemolysis were found to be Le(a-b-). One of them had anti-Leb antibodies during the acute phase of the disease, which disappeared during convalescence. Two other patients with previous infectious mononucleosis and hemolysis were found to be Le(a-b-) and Le(a+b-) respectively. Of the four patients, three were nonsecretors and the fourth likely to be so. The Lewis status of these four patients varies significantly from that of other patients with uncomplicated infectious mononucleosis and from the known distribution of the Lewis type in the Caucasian population. The findings suggest that the Lewis status of the patient is important in the development of hemolysis in infectious mononucleosis.

IgA deficiency, superior mediastinal tumour with unusual clinical manifestations.

The clinical course of a 17-year-old man with selective IgA deficiency and anaplastic carcinoma in the superior mediastinum is described. High swinging fevers, neutrophil leucocytosis reaching 60 x 10(9)/l, polyarthralgia and skin vasodilatation were unusual manifestations of the tumour. Marked tissue reactions in the neck and polyserositis occurred with a neutrophil granulocyte tissue reaction and progressed to fibrosis. Circulating immune complexes were present and IgE levels were grossly raised. It was not established whether the unusual clinical manifestations were due solely to the tumour or were an abnormal response of an IgA-deficient host. Review of the literature of malignancy in selective IgA deficiency casts doubt upon an increased incidence of neoplasm in this immune deficiency.

Interpretation of serum and red cell folate results. A comparison of microbiological and radioisotopic methods.

Serum folate and red blood cell folate levels were measured in 167 patients using a microbiological method (Lactobacillus casei) and a commercial 125I radioassay kit. The results of the two methods were compared and related to the clinical findings to see which method more truly reflected the physiological folate status of the patient. There was a good linear correlation between the methods for both serum folate and red cell folate over the whole range encountered and the mean results obtained with each method were nearly identical. Both methods seemed to perform equally well in distinguishing low serum folate levels, but when the red cell folate results were compared to the clinical and other laboratory findings, the radioassay more closely related to the folate status of the patient. The study again emphasized the high number of low serum folate levels found in hospital patients and the importance of measuring the red cell folate.