Markers of microbial translocation predict hypertension in HIV-infected individuals.

OBJECTIVES: The aim of the study was to test the hypothesis that microbial translocation, quantified by levels of lipopolysaccharide (LPS) and subsequent monocyte activation [soluble (sCD14)], is associated with hypertension in HIV-infected individuals. METHODS: In this exploratory substudy, 42 patients were recruited from a larger, longitudinal HIV-infected cohort study on blood pressure. LPS and sCD14 levels were measured retrospectively at the time of nadir CD4 cell count, selecting untreated HIV-infected patients with both advanced immunodeficiency and preserved immunocompetence at the time of nadir. Patients with later sustained hypertension (n = 16) or normotension (n = 26) throughout the study were identified. LPS was analysed using the Limulus Amebocyte Lysate colorimetric assay (Lonza, Walkersville, MD) and sCD14 using an enzyme-linked immunosorbent assay (ELISA). Nonparametric statistical tests were applied. RESULTS: In the HIV-infected patients [median (interquartile range) age 42 (32-46) years; 79% male and 81% Caucasian], LPS and sCD14 levels were both negatively correlated with nadir CD4 cell count. Plasma levels of LPS (P < 0.001) and sCD14 (P = 0.024) were elevated in patients with later hypertension compared with patients with normotension. There was a stepwise increase in the number of patients with hypertension across tertiles of LPS (P = 0.001) and sCD14 (P = 0.007). Both LPS and sCD14 were independent predictors of elevated blood pressure after adjustment for age and gender. For each 10-unit increase in LPS (range 66-272 pg/ml), the increment in mean blood pressure in the first period of blood pressure recording was 0.86 (95% confidence interval 0.31-1.41) mmHg (P = 0.003). CONCLUSIONS: As LPS and sCD14 were both independently associated with elevated blood pressure, microbial translocation may be linked to the development of hypertension.

Renal amyloidosis in intravenous heroin addicts with nephrotic syndrome and renal failure.

BACKGROUND: Renal amyloidosis has emerged as an important differential diagnosis when heroin addicts are admitted to renal clinics with proteinuria and nephrotic syndrome. MATERIAL: We present nine heroin addicts with renal AA amyloidosis, a condition previously not encountered in Norway, who were admitted to our renal clinic during the last 3.5 years. In the same time period a total of 209 patients were biopsied from native kidneys. RESULTS: Heroin abuse was associated with 70% of all biopsy-verified renal AA amyloidosis during this time period. Renal amyloidosis was found in 9 of the 12 heroin addicts that were biopsied. 6 of the 9 heroin addicts with amyloidosis required dialysis within 13 months after admission. CONCLUSION: Renal AA amyloidosis among heroin addicts seems to be associated with chronic suppurative skin infections. AA amyloidosis should always be considered in chronic heroin addicts presenting with proteinuria and renal impairment.

Relevance of a combined HIV antigen/antibody assay to detect early HIV infections in a low prevalence population: case reports.

The AxSYM HIV Ag/Ab Combo assay (Abbott) has proven to possess excellent sensitivity on seroconversion samples. Since its introduction in Sweden and Norway approximately one year ago, eight cases of acute HIV infections were found earlier compared to assays detecting only antibodies either to screen or to confirm an HIV infection. Data of the presented cases indicate that the early detection of primary HIV infection is of benefit to the individual patient and may reduce further spread of the disease. The impact of HIV combo assays on screening and diagnosis in a low prevalence population is discussed.

Immune responses and clinical outcome of massive human osteoarticular allografts.

Cell mediated immune responses as measured by lymphocyte proliferation induced by the mitogens phytohemagglutinin and concanavalin A and antigen extracts of donor derived bone were studied within 2 years after wide resection of bone tumors in 18 patients receiving fresh frozen massive osteoarticular allografts. No uniform changes were seen in mitogen induced responses in 18 patients. However, five of nine patients tested with antigen extracts of donor derived bone showed elevated immune responses, one moderate and four weak. The incorporation of the allograft (evaluated by repeated radiographs; specific isotope techniques; clinical outcome assessed by the functional rating scores of Mankin-Waber and the Musculoskeletal Tumor Society; and histologic biopsy findings on new bone formation) did not differ in these patients from those in patients without any response to donor derived tissue. During a long term followup (mean, 11 years; range, 2-20 years), degenerative joint and sclerotic density bone changes developed after 2 to 4 years without correlation to immune responses. Histologic specimens showed no signs of immunologic reaction, and no clinical rejection episodes were recorded. A slightly variable immune response to allograft bone seems to occur, but its clinical significance for outcome of the grafts remains to be determined. The low immune responses might reflect a low antigen release rate through an indirect pathway or immunologic tolerance to antigens or proteins shed from massive allografts that are nonliving scaffold implants during the creeping substitution process, corresponding to the low immune response and the slow histologic repair.

Aseptic spondylitis as the initial manifestation of the SAPHO syndrome.

We describe the case of a 61-year-old female patient who presented with spondylitis of the lumbar spine. Although the microbiological cultures of the bone biopsy specimens obtained during laminotomy remained negative, the patient was treated with broad-spectrum antimicrobials for 2 months. Eight months later she started to suffer from pain and tenderness in her sternum and the medial portion of her left clavicle. The findings of computed tomography and gallium-labelled isotope scan were indicative of sternoclavicular arthritis. Again, all surgically obtained biopsy specimens yielded negative results in microbiological studies. The diagnosis of the SAPHO (synovitis, acne, pustulosis, hyperostosis, and osteomyelitis) syndrome was then made based on the clinical presentation with recurrent sterile osteitis in two characteristic locations, and the patient was started on immunosuppressive therapy. This case is a reminder that SAPHO may sometimes occur without any skin manifestations. Since this type of patient may be admitted to an orthopedic ward, it is important that orthopedic surgeons are familiar with the syndrome.

Propionibacterium acnes isolated from sternal osteitis in a patient with SAPHO syndrome.

A woman presented with palmar pustulosis and deep chest pain in association with osteitic lesions in the lower part of the sternum. Propionibacterium acnes was isolated and grew in pure culture from 6 surgically obtained bone specimens. The patient received clindamycin treatment for 6 months. Synovitis in both her wrists persisted and, based on a clinical suspicion of seronegative rheumatoid arthritis, she was treated with intramuscular gold and methotrexate with no apparent benefit. Subsequently, she was diagnosed with SAPHO syndrome (synovitis, acne, pustulosis, hyperostosis, and osteomyelitis). Our patient provides further data on the potential association between P. acnes and SAPHO syndrome.

MR imaging in the presence of small circular metallic implants. Assessment of thermal injuries.

PURPOSE: The thermal effects of MR imaging in the presence of circular nonferro-magnetic metallic implants were studied in 6 rabbits. MATERIAL AND METHODS: A sternotomy was performed and fixed with stainless steel wires, and small titanium rings (diameter 3 mm) were placed on the surface of the ascending aorta and subcutaneous tissue of the thigh. Four of the rabbits were exposed to an imaging procedure with a 1.5 T scanner applying a T1-weighted spin-echo sequence and a gradient echo sequence. Two of the animals served as unexposed controls. Thirty-six hours after the exposure, tissues adjacent to the implants were examined histologically and compared with corresponding samples of the control animals. RESULTS: In the area of the titanium rings, histologic analysis revealed slight inflammatory changes apparently caused by the operation. No evidence of thermal injury was found, suggesting that the presence of the rings does not contraindicate MR examinations. Necrosis was noted in all of the sternal specimens. This was probably post-operative, but it impaired the assessment of thermal injury in this area.

An aseptic inflammation of the clavicle in a patient with Crohn's disease. A potential manifestation of the SAPHO syndrome.

A female patient with Crohn's disease developed an septic osteoarticular involvement of the left clavicle and sterno- and acromioclavicular regions. Repeated surgical revisions combined with a broad-spectrum antimicrobial treatment could not prevent the progress of the disease. However, the patient started to improve after the diagnosis of the SAPHO (synovitis, acne, pustulosis, hyperostosis and osteomyelitis) syndrome was made and the dose of her immunosuppressive therapy increased. This patient reminds of the existence of extraintestinal aseptic infections in association with inflammatory bowel disease (IBD). Moreover, it may provide further evidence on the significant association between SAPHO and IBD.

Massive osteoarticular knee allografts: structural changes evaluated with CT.

PURPOSE: To analyze the structural changes seen at computed tomography (CT), particularly the findings that precede insufficiency (fatigue) fractures in massive osteoarticular knee allografts. MATERIALS AND METHODS: The subchondral and cancellous bone of 12 allografts were retrospectively evaluated with repeat transaxial CT (mean follow-up, 53 months). RESULTS: Early cortical graft resorption was followed by slow thickening after 6 months. Formation of resorptive cysts increased the cortical irregularity, which leveled off after 2 years. Late remodeling was evident as a subcortical sclerotic rim, "neocortex." Initially, the cancellous graft bone showed higher attenuation than the host bone; this difference subsided gradually during the first 3 years. Four insufficiency fractures were detected after the 1st postoperative year. Poor remodeling preceded these fractures. CONCLUSION: CT effectively depicted the structural changes during allograft incorporation and was superior to plain radiography for the detection of insufficiency fractures. The use of CT for follow-up of massive osteoarticular knee allografts provides additional information concerning the readiness of the graft for weight bearing.