A case of secondary hyperparathyroidism whose high turnover bone improved after the direct injection of acetic acid into the parathyroid glands.

A 48-year-old male was admitted to our hospital because of increasing knee pain and thigh muscle weakness. He had been undergoing hemodialysis for 15 years. His serum intact PTH value was 1,600 pg/ml with elevated ALP (387 IU/l) and osteocalcin (400 ng/ml). Ultrasound (US) examination disclosed 2 enlarged parathyroid glands. Because of poor cardiac function, an US-guided acetic acid injection into the enlarged parathyroids (percutaneous acetic acid injection therapy; PAIT) was performed. Soon after the PAIT, his arthralgia disappeared. Serum PTH fell to 220 pg/ml with the regression of bone marker 1 year following the PAIT. The size of his parathyroid glands dramatically regressed and 1 of the enlarged glands finally disappeared. Repeated bone biopsies following double tetracycline labeling showed a significant improvement from osteitis fibrosa to the mild lesion. This is the first known case report of severe secondary hyperparathyroidism whose PTH and high turnover bone was successfully managed by the direct injection of acetic acid into the parathyroid glands. As long as we pay attention to avoiding recurrent nerve palsy induced by acetic acid, US-guided PAIT may be an alternative to percutaneous ethanol injection therapy (PEIT) or surgical parathyroidectomy (PTx).

Removal of digoxin by column for specific adsorption of beta(2)-microglobulin: a potential use for digoxin intoxication.

BACKGROUND: A beta(2)-microglobulin adsorption column used for the treatment of dialysis-related amyloidosis removes serum beta(2)-microglobulin by recognition of lipophilic residue in the protein. No data are available for the adsorption of the highly lipophilic drug digoxin. METHODS: In vivo clearance of digoxin with the beta(2)-microglobulin column was measured by a single use of the column in 8 patients receiving hemodialysis with a therapeutic level of digoxin. In vitro adsorption was evaluated by use of incubation with adsorbent of the column and digoxin or ranitidine, a hydrophilic drug. Clearance with the beta(2)-microglobulin column was further compared with that obtained by use of activated charcoal in the dogs intoxicated with digoxin. RESULTS: Digoxin concentration was reduced from 1.11 +/- 0.25 ng/mL to 0.57 +/- 0.15 ng/mL at 240 minutes after initiation of hemoperfusion with the column in the patients. Digoxin clearance with the beta(2)-microglobulin column was about 145 +/- 20 mL/min, with a blood flow rate of 160 to 220 mL/min (80% of plasma flow rate). Eighty-five percent of digoxin was adsorbed in vitro, and the capacity of the beta(2)-microglobulin column was not saturated until a toxic level was reached (50 ng/mL). This value was higher than that obtained with use of charcoal. In dogs with digoxin intoxication, digoxin clearance was 38.9 +/- 1.5 mL/min, with a blood flow rate of 50 mL/min (95% of plasma flow rate), which was almost twice as that achieved with charcoal. The degree of thrombocytopenia and leukopenia was small with use of the beta(2)-microglobulin column. CONCLUSION: These data suggested that the beta(2)-microglobulin column selectively adsorbs digoxin. This column is a promising tool for the treatment of digoxin intoxication, especially in patients undergoing hemodialysis.

Clonotypes of Staphylococcus aureus isolated from continuous ambulatory peritoneal dialysis patients: what is the vector between nares and infection site?

Staphylococcus aureus is frequently isolated from patients with infections related to continuous ambulatory peritoneal dialysis (CAPD). In many cases, the organism is also isolated simultaneously from the anterior nares. To clarify the transmission trail of S. aureus, we used DNA analysis to identify clonotypes of clinical strains. The nares and exit sites of 32 CAPD patients were swabbed, and PD fluid samples were taken for pathogen culture. Genome DNA of S. aureus was digested with restriction enzyme Sma I for pulsed-field gel electrophoresis. We also asked the patients how they usually performed the PD procedure. S. aureus was isolated from 4 patients, including 3 who hosted two strains isolated separately from different sites. The DNA patterns of the strains isolated from these latter 3 patients were identical. However, the clonotypes from all 4 patients were different. Most of the patients did not wash their hands and wear masks while exchanging PD bags and caring for their exit sites. After the patients were disinfected and re-educated in proper procedures, S. aureus was not detected in any of them. These data suggest that no outbreak occurred in our hospital and that the vectors of endogenous infection were the patients themselves, probably their hands. A bacteriological study presents an efficient opportunity to re-educate patients in PD procedure.

Effects of "isolating hemodialysis" on prevention of methicillin-resistant Staphylococcus aureus cross-infection in a hemodialysis unit.

AIM: To evaluate the effects of a contact isolation program against methicillin-resistant Staphylococcus aureus (MRSA) cross-infection among patients in a hemodialysis unit. CLINICAL SETTING AND METHODS: In all patients maintaining hemodialysis therapy were tested for MRSA infection and who had MRSA infection, not only inpatients but also outpatients were separated into a designated area (isolating hemodialysis). Clinically isolated MRSA strains were clonotyped with coagulase typing, staphylococcal enterotoxin typing and restriction enzyme analysis of plasmid DNA. RESULTS: The frequency of patients with MRSA infection was 4.5% before starting this protocol and was reduced to 2.9% two and a half years later. At this time, MRSA was isolated from the 8 patients. These 8 clinical strains were differentiated into 6 clonotypes and 3 strains showed the same patterns. Two of 3 were isolated from inpatients and the other was from a patient with community onset MRSA colitis. In this case, most MRSA infections were independent under prophylaxis control and cross-infection was observed only once between hospitalized patients who stayed in a same ward. CONCLUSION: This "isolating hemodialysis" should be useful to prevent cross-infection among patients in end-stage renal disease in a dialysis unit.

Crossed cerebellocerebral diaschisis in patients with cerebellar stroke.

OBJECTIVES: We performed single-photon emission computed tomography (SPECT) to investigate crossed cerebellocerebral diaschisis (CCCD) in patients with cerebellar stroke. MATERIAL AND METHODS: Fifteen patients with unilateral cerebellar stroke underwent SPECT of the brain with N-isopropyl-p-[123I] iodoamphetamine (123I-IMP). Regional cerebral blood flow (rCBF) was measured by the autoradiographic method. Regions of interest were defined in the cerebral cortex, striatum, thalamus and cerebellum to compare structures (contralateral to the cerebellar lesion) with counterparts ipsilateral to the stroke. RESULTS: In the frontal and parietal cortices, especially the posterior superior frontal, anterior midfrontal, precentral, postcentral, and supramarginal areas, rCBF contralateral to the lesion was significantly lower than on the side of the lesion (showing CCCD). CONCLUSION: This CCCD phenomenon is important to be aware of in clinical reading of images.

Synergistic bactericidal effects of acrinol and tetracycline against Pseudomonas aeruginosa.

Combined treatment of acrinol (Ac) and tetracycline hydrochloride (Tc) against Pseudomonas aeruginosa strains isolated from clinical specimens synergistically increased the bactericidal effect. The minimum bactericidal concentration (MBC) of Ac against P. aeruginosa strain no. 985 was 200 microg/ml, while the MBC of Ac against strains no. 47 and no. 783 was above 800 microg/ml for each. The MBC of Tc was above 400 microg/ml against each of the tested strains. However, simultaneous treatment with 25 microg/ml Ac and 200 microg/ml Tc against P. aeruginosa strain no. 985 decreased the viable cell number from 107 cfu/ml to <10 cfu/ml within 24 h, while a higher concentration of Tc (400 microg/ml) with Ac (25 microg/ml) reduced the viable cell number to <10 cfu/ml within 8 h. A similar synergistic bactericidal effect of Ac and Tc was observed in strains no. 47 and no. 783 by treatment with 200 microg/ml Ac and 200 microg/ml or 400 microg/ml Tc. The degree of bactericidal effect against P. aeruginosa was proportional to the concentration of Tc under the condition of a constant concentration of Ac. Furthermore, Ac-treated cells of strain no. 47 were killed by a following Tc treatment, but cells pretreated with Tc did not show such a sensitivity to Ac. To induce the synergistic effect of Ac and Tc, Ac must be applied to P. aeruginosa before or at the same time as Tc.

[A case of interstitial nephritis induced by a super antigen produced by methicillin-resistant Staphylococcus aureus (MRSA) presenting as acute renal failure].

We report the case of a 21-year-old man who had been developing acute renal failure with Methicillin-resistant Staphylococcus aureus (MRSA) colitis and sepsis. He was admitted for consciousness disturbance, nausea, vomiting, and diarrhea. Oliguria was also observed and his serum creatinine level was elevated to 10 mg/dl. Urinary protein was positive and an abundance of hyaline cast were seen in urinary sedimentation. Diarrhea and pyrexia were prolonged and serum C-reactive proteins were elevated, but lymphocyte and leukocyte counts temporarily decreased from the 3rd to the 6th hospital day and remained low until normalizing after the 14th day. His clinical symptoms improved with hemodialysis (HD) and effective antibiotic therapies. An MRSA strain producing toxic shock syndrome toxin-1 (TSST-1), a super antigen which specifically stimulates human V beta 2-positive T cells, was separated from his feces and blood. To ascertain the cause of his renal dysfunction, a renal biopsy was performed on the 8th day. His renal histology revealed acute interstitial nephritis with severe inflammatory cell infiltration around the medullary areas without glomerular changes. Most of the infiltrated cells were small monocytes, and lymphoid cells were rich in the interstitium. With immunohistochemical staining, over 70% of T-cells were V beta 2-positive. TSST-1-producing MRSA was detected in his blood specimen. Furthermore, V beta 2-positive T cells were accumulated in the renal intersititium, and transient lymphocytopenia was observed. These data suggested the following possible pathogenesis for interstitial nephritis: TSST-1 acts as a super antigen in the renal interstitium where major histocompatibility complex (MHC) is class-2-positive, thereby resulting in interstitial nephritis with T cell migration.

Insertion/deletion polymorphism in intron 16 of the ACE gene and left ventricular hypertrophy in patients with end-stage renal disease.

We studied the relationship between polymorphism in intron 16 of the angiotensin-converting enzyme (ACE) gene and left ventricular (LV) hypertrophy in uremic patients treated with hemodialysis therapy. The LV parameters were not different for age-, hematocrit-, and blood pressure-matched patients in DD, ID, and II genotype groups. The most important factor for LV hypertrophy was systolic blood pressure, which correlated with the posterior wall thickness (r=0.35; P=0.001) and LV mass index (LVMI; r=0.23; P=0.032). Among nonhypertensive patients, the frequency of interventricular septum (IVS) hypertrophy (>12 mm) and hypertrophy in LVMI (>145 g/m2) was significantly greater in patients with the DD genotype than in I allele-positive (+) patients. The odds rate for IVS hypertrophy was 5.04 (95% confidence interval, 1.15 to 24.8). These data suggest that the DD genotype of the ACE gene polymorphism is a contributory factor for the development of LV hypertrophy in patients with end-stage renal disease (ESRD).

[Association analysis of angiotensin-converting enzyme gene polymorphism with end-stage renal disease].

BACKGROUND: Intron 16 insertion/deletion (I/D) polymorphism in the angiotensin-converting enzyme (ACE) gene may be associated with the progression of renal insufficiency in patients with renal diseases. The objective of this study was to determine whether D allele is a risk factor for the progression of the disease in end-stage renal disease (ESRD) patients. METHODS: Using PCR techniques, genetic analysis of the ACE I/D polymorphism was performed on 326 dialysis patients. We compared the distribution of genotypes and allele frequency of this polymorphism in dialysis patients and the normal Japanese population. The clinical courses of 47 patients were studied retrospectively, and the progression of chronic renal failure using time plots of the reciprocal of serum creatinine (1/Cr) was estimated. RESULTS AND CONCLUSION: The frequencies for II, ID, and DD genotypes were 134, 148 and 44, respectively. The frequency for I allele was 0.64, and for D allele 0.36. These results were similar to the frequencies found in the normal Japanese population. However, patients with polycystic kidney disease (PKD) showed a high frequency for D allele (0.54: p = 0.023 by chi 2 method). In longitudinal courses, we did not find any association between ACE gene polymorphism and the declining rate of renal function. However, in patients with PKD, the DD genotype may influence the clinical course of renal disease.

Changes in arrangement and in conformation of molecular components of peripheral T-cell antigen receptor complex after ligand binding: analyses by co-precipitation profiles.

Amounts of co-precipitating CD3 components by anti-T-cell receptor (TCR)V beta or anti-CD4/8 monoclonal antibodies were compared between non-stimulated and stimulated splenic T cells. The amounts of co-precipitating CD3 delta, epsilon and gamma chains with TCR alpha beta and with CD4/8 were not significantly changed after TCR ligation. The apparent amount of CD3 zeta chain co-precipitated with TCR alpha beta increased up to threefold, while the actual amount of co-precipitating CD3 zeta with TCR alpha beta and the total amount of specifically precipitated CD3 zeta are not changed after cross linking of TCR. The apparent amount of CD3 zeta chain co-precipitated with CD4/8 also increased. Unlike co-precipitation with TCR alpha beta, the actual amount of CD3 zeta co-precipitated with CD4/8 increased significantly. This observation suggests a conformational change as well as the relocation of CD3 zeta molecules within the TCR complex after the signal delivery. After TCR ligation, CD3 zeta chains relocate to the vicinity of either CD4 or CD8 molecules. In addition, when cross linking and binding signals are compared, CD3 chains undergo two distinct phases of conformational change. The responses, while the later conformational change caused by the cross linking of TCR does not induce but enhances the proliferative response.

T-cell activation modified by parathyroid hormone (PTH) in patients with end-stage renal disease.

We studied the effect of parathyroid hormone (PTH) on the proliferation of T cells from patients with end-stage renal disease (ESRD) (n = 16) and normal subjects (n = 20). In patients with ESRD, T-cell proliferation expressed as stimulation index (SI) was significantly decreased from 99.2 +/- 31.2 to 46.3 +/- 10.8, when 10 ng/ml of recombinant PTH (rPTH) was added in vitro. The reduction of SI with rPTH was dose dependent. However, in normal subjects, the SI was increased from 56.2 +/- 13.6 to 67.9 +/- 16.5 (p < 0.01) by addition of rPTH. These findings were also shown by allo or specific antigen-induced T-cell stimulation. When T cells from normal subjects were pretreated with 10 ng/ml of PTH, with 100 mg/dl of urea or with a condition of pH 7.0, the effect of rPTH was changed to decrease the T-cell proliferation induced by anti-CD3 antibody. These data suggested that uremic state, including hyperparathyroidism, changed the response of T cells against PTH.

Efficacy of gentian violet in the eradication of methicillin-resistant Staphylococcus aureus from skin lesions.

The efficacy of gentian violet (Gv) in eradicating methicillin-resistant Staphylococcus aureus (MRSA) in decubitus ulcers was investigated. Decubitus ulcers (a total of 18 cases) were scrubbed with Gv aqueous solution 0.1% and ointment containing Gv 0.1% was applied daily. MRSA was not detected in these lesions for 3-34 days (average, 10.5 +/- 2.5 days) after the application of Gv ointment. Before this trial, all patients were treated with povidone-iodine and antibiotics; however, those treatments were not effective in eradicating MRSA from skin lesions. Skin irritation and other systemic side effects caused by Gv were not observed. Our data suggest that Gv is a useful agent for treatment of the decubitus ulcers infected with MRSA.

Control of sodium and chloride transport in the thick ascending limb in the avian nephron.

We previously reported that birds may concentrate urine by a countercurrent multiplier mechanism using single-solute (NaCl) recirculation, in which the thick ascending limb of Henle (TAL) of mammalian-type nephrons provides an energy source. The Japanese quail TAL has a higher lumen-to-bath Cl flux (JCl,lb) than that of mammals; the mechanism for maintaining the osmotic gradient along the medullary cone is unknown. We investigated whether salt delivery alters the NaCl reabsorption rate in the TAL dissected from both normal and salt-loaded Japanese quail, Coturnix coturnix, 3-7 wk old. When salt loading to the TAL was increased by increasing the perfusion flow rate (PFR), the lumen-to-bath Na and Cl flux coefficients (KNa,lb or KCl,lb, 10(-7) cm2/s) increased, respectively (P < 0.05), from 5.1 +/- 0.9 to 7.6 +/- 0.7 and from 6.8 +/- 0.9 to 8.9 +/- 1.4. Ouabain addition significantly reduced the KNa,lb. A significant correlation existed between PFR and JCl,lb (r = 0.69, P < 0.01) and PFR and JNa,lb. When the TAL was perfused at a low PFR, increasing Cl concentration in the perfusate and bathing medium from 125 to 175 (P < 0.05) or 225 mM (P < 0.01) increased JCl,lb but not KCl,lb, while decreasing Cl concentration decreased JCl,lb but not KCl,lb. Salt loading of intact birds (0.2 M NaCl drinking water) for 7 days increased the plasma Na level and the cloacal fluid-to-plasma osmolality ratio from 0.28 +/- 0.07 to 1.06 +/- 0.05 (P < 0.01).(ABSTRACT TRUNCATED AT 250 WORDS)