[Pseudoaneurysm of the hepatic artery presenting with hemobilia--a complication of laparoscopic cholecystectomy]. / Pseudoaneurysma arteria hepatica manifestující se hemobilií jako komplikace laparoskopické cholecystektomie.

INTRODUCTION: Hemobilia, defined as a bleeding into the bile duct, is a rare disease. One of its infrequent causes is a hepatic artery pseudoaneurysm, usually developed after arterial iatrogenic leasion. MATERIAL AND METHODS: A case review, presenting right hepatic artery pseudoaneurysm with a biliovascular fistula as a consequence of hepatic artery and bile duct injuries during "uncomplicated" laparoscopic cholecystectomy. DISCUSSION: Bile duct injury is one of the most serious complication after laparoscopic cholecystectomy. Hepatic artery may be injured simultaneously, resulting in the pseudoaneurysm and/or biliovascular fistula, presenting with hemobilia. Time interval from the injury to symptoms widely varies from few hours to weeks or even several months. CONCLUSION: Melena or hematemesis after recent laparoscopic cholecystectomy should be always suspicious from hepatic artery and/or bile duct injuries, manifesting with hemobilia.

[Infliximab in the treatment of Wegener's granulomatosis: case report]. / Infliximab v lécbe Wegenerovy granulomatózy: kazuistika.

PURPOSE: to evaluate the efficacy of monoclonal anti-tumor necrosis factor alpha antibody infliximab in treatment of refractory Wegene's granulomatosis. Clinical manifestations of Wegener's granulomatosis at the time of infliximab initiation were: proptosis of both eyes due to progressive retrobulbar granulomas, visual impairment, optic disc edema, progressive diplopia, sinus and renal involvement. The disease was refractory to a treatment with various immunosuppressants, including intravenous cyclophosphamide or high doses of mycophenolate mofetil in combination with corticosteroids. METHODS: Observational case report. RESULTS: the patient received six infusions of infliximab (3 mg/kg) in addition to low doses of oral cyclophosphamide and corticosteroids. The interval between the first two infusions was 1 week. The interval between the second and third infusions was 4 weeks, thereafter 8, 12 and 34 weeks. Following the third infusion of infliximab the remission of Wegener's granulomatosis was seen. After the regression of retrobulbar granulomas visual acuity increased, ocular motility improved, diplopia and optic disc edema decreased. Remission has been maintained for 17 months. Infliximab was well tolerated during the short-term follow-up. CONCLUSION: Infliximab successfully induced remission in case of sight-threatening Wegener's granulomatosis in our patient. It seems that infliximab provides more effective therapeutic option in treatment of Wegener's granulomatosis refractory to standard immunosuppression and offers better perspectives for patients with previously poor prognosis. Furthermore, it enables reducing the exposure to immunosuppressive drugs.

[The chemiluminescence test in the laboratory evaluation of effects of immunostimulatory therapy]. / Vyuzití chemiluminiscencního testu pro laboratorní hodnocení úcinku imunostimulacní lécby.

BACKGROUND: Number of patients treated by general practitioners with various immunomodulatory drugs has recently increased. Effects of such medication on the immune system were not usually monitored. The aim of our work was to evaluate effect of selected immunomodulatory drugs on the phagocytic and metabolic activities of the phagocytes. METHODS AND RESULTS: 51 patients (18 males and 33 females) of the average age 36 years with repeating respiratory, mycotic and herpetic infections were investigated. Immunomodulatory treatment included: Decaris (Lavamizolum), Isoprinosine (Methisoprinolum), Imudon (Lysatum bacteriale mixtum), Biostim (Klebsiella pneumoniae), and Immodin (Leukocyti dialysati lyophylysatum). Before and after treatment all patients underwent basic immunological examination IgG, IgA, IgM, C3, C4 complement components, PEG, CD3, CD4, CD8 and CD19). Phagocytotic activity was estimated by means of FAGO MSHP test with HEMA particles and by chemiluminiscence test. Chemiluminiscence was measured using ML 3000 Microtiter Plate Luminometer (Dynex), 26 healthy individuals of the corresponding age were the controls. Results were statistically evaluated by Student's t-test. Significant increase of the cellular metabolic activity was found in Decaris and Immodin treated patients (P < 0.001). CONCLUSIONS: Chemiluminiscence test, which evaluates the metabolic activity of phagocytes, can be used for the accurate laboratory monitoring of the effects of some immunomodulatory drugs on the natural immunity of patients.

[CD5-positive B lymphocytes and antinuclear antibodies]. / CD5 pozitivní B lymfocyty a antinukleární protilátky.

BACKGROUND: The production of natural autoantibodies incl. antinuclear antibodies (ANA) is ascribed to lymphocytes which have a CD5 molecule on their surface. The role of CD5 positive B lymphocytes in the induction of autoimmunity is obscure so far. The authors focused their attention on the incidence of antinuclear antibodies (AA) in subjects with different diseases and sought a relationship with the ratio of CD5 positive B lymphocytes in the peripheral blood stream. METHODS AND RESULTS: CD5 positive lymphocytes were assessed on a flow cytometer using monoclonal anti CD5 and anti CD19 antibodies. Antinuclear antibodies are detected by indirect fluorescence on a substrate of human leucocytes and HEP-2 cells. In a group of 134 subjects the authors did not provide evidence of a direct relationship between the relative number of CD5 positive B lymphocytes in the peripheral blood stream and the presence of ANA (IgG, IgA, IgM), not even in 33 patients with autoimmune diseases. In 86 patients the authors revealed that antinuclear antibodies type IgM predominate in patients with repeated respiratory infections. In systemic diseases the isotype IgG predominates (p = 0.01). After immunosuppressive treatment with a favourable clinical effect the ANA isotype IgG disappears and isotype IgM is found more frequently. The incidence of the ANA isotype IgM is significantly higher in healthy subjects aged over 60 years than in younger subjects (12.5%/6.1%, p = 0.06), and more frequent in women (p = 0.05). CONCLUSIONS: The presence of antinuclear antibodies is not associated with the amount of CD5 positive B lymphocyte in the peripheral blood stream.

[Diagnosis and therapy of Wegener's granulomatosis based on ocular changes]. / Diagnóza a lécba Wegenerovy granulomatózy na podklade ocních zmen.

The authors draw attention to the different ophthalmological manifestations of Wegener's granulomatosis in two patients examined at the First Ophthalmological Clinic of the First Medical Faculty, Charles University, Prague. The patients complaints led later to establishment of the diagnosis of WG or its relapse. Combined immunosuppressive treatment with steroids and cyclophosphamide relieved the ocular as well as general manifestations of WG.

[Acute anterior uveitis, systemic diseases and HLA-B27]. / Akutní prední uveitida, systémové choroby a HLA-B27.

The author investigated the rate of phenotype HLA-B27 and systemic diseases in patients with acute anterior uveitis (AAU) in our geographical area. The evaluated clinical differences of AAU manifestations in HLA-B27 positive and HLA-B27 negative patients in a group of 104 subjects followed up for a 10-year period. The patients were under 40 years of age. Men were affected twice as frequently as women. HLA B27 positive AAU is manifested above all by serofibrous exsudation into the anterior chamber and by more frequent relapses. In patients with early treatment there were fewer complications and the prognosis was favourable. AAU in HLA-B27 positive patients is associated in 65% with rheumatic disease. In our population it is above all ankylosing spondylitis and Reiter's disease. In 71% rheumatic diseases were manifested in men. Despite the different clinical course of AAU HLA-B27 positive and negative patients, during long-term follow up the visual acuity is not markedly altered in any of the investigated groups.

[Behcet's disease]. / Behcetova nemoc.

The author evaluates diagnostic and therapeutic results in nine patients with Behcet's disease investigated at the uveological ambulance of the First Ophthalmological Clinic, Medical Faculty Charles University in Prague during 1987-1996. Anterior uveitis with hypopyon was recorded twice as frequently as retinal vasculitis. Chronic CME, secondary glaucoma and occlusive vasculitis were the most serious complications of ophthalmological manifestations of BD. Ulcerations of connective tissue and skin manifestations of BD were found most frequently in the authors patients. In two thirds of the patients also the risk phenotype HLA B5 was recorded.

[Diagnosis of uveitis with laboratory tests and specialized examinations]. / Prínos laboratorních a specializovaných vysetrení k diagnostice uveitidy.

The authors evaluated the importance of a large scale of laboratory examinations and specialized examinations in a group of 174 patients with endogenous uveitis examined at the uveological ambulance of the First Ophthalmological Clinic of the First Faculty, Charles University Prague. Laboratory examinations which are part of screening examinations are of little value for the diagnosis of uveitis. Alone they are unable to assess its type or prognosis. They cannot be recommended for routine work in the field. Only the incidence of phenotype HLA B27 in patients with anterior uveitis is, as compared with the healthy population, statistically significant (p < 0.005). Aimed collaboration with specialists from other disciplines is more important. The latter can on the basis of aimed examinations confirm or rule out systemic disease of a patient with uveitis suspected by the ophthalmologist.

[Treatment of herpes simplex keratouveitis with systemic and local administration of acyclovir]. / Lécba herpes simplex keratouveitidy celkove a lokálne podaným acyclovirem.

Sixteen patients with relapsing or chronic HSV keratouveitis were treated during a new attack by acyclovir 15 mg/kg/day by the i.v. route for 5 days with local combination of acyclovir 3% ung. and steroids. In all 16 patients improvement of signs of keratouveitis occurred on the fourth day of therapy, in 10 patients with improvement of visual acuity. In 5 patients perforating keratoplasty was performed on account of turbidity of the cornea. The authors observed four relapses of the disease in the course of 12 months after termination of treatment.

[Cataract surgery in patients with endogenous uveitis]. / Operace katarakty u pacientu s endogenní uveitidou.

The authors present an account of surgery of complicated cataract in 20 patients with anterior and intermediate uveitis. During a one-year follow-up period they evaluate the difference of postoperative development and visual acuity in extracapsular extraction without or with implantation of an intraocular lens. In 10 patients (5x m. Fuchs, 3x anterior uveitis, 2x intermediate uveitis) they performed only ECCE. In 10 patients with the same diagnosis an intraocular lens was implemented. The authors did not find marked differences between the ECCE operation and ECCE operation with an intraocular lens in patients with uveitis. The visual acuity improved in all 20 patients, a marked inflammatory reaction in the anterior chamber was observed in both groups only during the first days after surgery. The two groups did not differ markedly as regards late complications. From the investigation ensues that implantation of an intraocular lens is well tolerated in patients with anterior and intermediate uveitis assuming a minimum 12-week remission of the disease.

[The spectrum of diseases associated with antineutrophil cytoplasmic antibodies]. / Spektrum chorob sdruzených s výskytem protilátek proti cytoplazme neutrofilu.

BACKGROUND: Antineutrophil cytoplasmic antibodies (ANCA) are considered as a diagnostic marker of systemic vasculitis and rapidly progressing glomerulonephritis. They are frequently associated with other pathological conditions. The author's objective was to analyze a group of patients examined at the Department of Clinical Immunology of the First Medical Faculty Charles University in the course of one year and evaluation of the diagnostic asset of the ANCA examination. METHODS AND RESULTS: ANCA was assessed in serum using the method of indirect immunofluorescence. In cases of p-ANCA the ELISA test was used to assess antimyeloperoxidase antibodies. Clinical data were evaluated on the basis of analysis of a questionnaire sent to doctors of patients where ANCA was detected. In 1992 1010 specimens were examined and in 115 ANCA was detected. This was the case in a group of 65 patients with the following diagnoses: systemic vasculitis 26x, systemic immunopathological diseases 12x, renal diseases 9x, inflammatory bowel diseases 7x, inflammatory eye diseases 6x, monoclonal paraproteinaemia 2x, other 4x. The patients had renal affections (45%), affections of the joints (20%), skin (18%), eyes (14%), lungs (12%), GIT (11%), ENT (9%), and nerves (9%). Type c in titres above 1:160 was always associated with the diagnosis of Wegener's granulomotosis, in other instances c- or x-types titres of 1:20 were involved. Antibodies against myeloperoxidase were detected in four instances. CONCLUSIONS: The authors confirmed that c-ANCA in high concentrations are specific for the predominantly active form of Wegener's granulomatosis. The group of patients with p-ANCA is too small to generalize the diagnostic impact. Low ANCA concentrations are found in many other diseases. The importance of ANCA can be evaluated only in a clinical context and the importance of their presence must not be overestimated.

[Initial experience with therapy of endogenous uveitis with Consupren--the Czech cyclosporin A]. / První zkusenosti s terapií endogenní uveitidy Consuprenem--ceským cyklosporinem A.

The authors treated as part of a controlled trial, five patients with Consupren, Galen a Co, i.e. the Czech preparation of cyclosporin A. All patients suffered from endogenous uveitis which was refractory to treatment with a combination of prednisone and cyclophosphamide or prednisone and azathioprin. Mitigation of the disease was achieved already during the first three weeks of treatment. In two patients during treatment a slight relapse of the inflammation was observed. As to side effects of this treatment, the authors observed only once readily controllable hypertension and a rise of some indicators of liver metabolism which returned to normal already during treatment. Side-effect in conjunction with renal affection were not observed in any of the patients. Based on these preliminary results the authors assume that Consupren is in the given indication, and when the described pattern of administration is used, effective and justifies the authors to continue with their investigation.

[Endogenous uveitis]. / K problematice endogenní uveitidy.

In a brief historical review of views on inflammatory affections of the uveal tissue the authors focused attention also on distinguished personalities in Czech ophthalmology who worked at the Czech Ophthalmological Clinic and participated in the development of uveology. Based on their own observations, they give an account on of their experience with the diagnosis of endogenous uveitis. Consistent with the world literature, they were able to reveal in a group of 174 patients with endogenous uveitis that the condition was associated with a systemic disease in 30%, in 9% they found an infectious aetiology and the remaining 61% were described as idiopathic endogenous uveitis. From the group of idiopathic uveitis they separated clinical entities diagnosed in 29%.

[Immunologic mechanisms and the effect of immunosuppressive therapy in ophthalmology]. / Imunologické mechanismy a jejich ovlivnení imunosupresívní terapií v ocním lékarství.

The authors mention some immunopathological mechanisms which participate in the beginning and maintenance of activity in so-called idiopathic endogenous uveitis. They draw attention to the possibility to influence these mechanisms by immunosuppressive treatment, mention its advantages and the feasibility of risk of undesirable side-effects. The authors assume that it is useful to use corticoids and cytotoxic substances as well as the more aimed action on immunity exerted by Cyclosporine A.

[Personal experience with immunosuppressive therapy of endogenous uveitis]. / Nase zkusenosti s imunosupresívní lécbou endogenní uveitidy.

The authors investigated 43 patients with the original diagnosis of endogenous idiopathic uveitis for a period of one year. Comprehensive ophthalmological, immunological and rheumatological examination revealed that in all investigated cases either systemic disease was involved or diseases associated with impaired immunity or endogenous idiopathic uveitis. The patients were treated by immunosuppressive therapy either by Prednisone alone or by a combination of Prednisone and Cyclophosphamide. In all instances remission was achieved, contrary to previous therapy employed in these patients. In the majority of patients/21 of 23 and 12 of 18 resp./remission persisted for at least one year. The authors discuss indications and pitfalls of immunosuppressive therapy based on recommendations found in the literature.

[Ocular involvement in Lyme disease]. / Postizení oka pri Lymské nemoci.

Lyme disease is a tick-born multisystemic disease, caused by the Spirochete Borrelia burgdorferi. We examined and treated a 60-year-old woman, who 6 months after a tick bite had developed bilateral uveitis, with the involvement of the anterior segment, vitreous opacities and retinal vasculitis. The ocular involvement was, besides the skin lesion in the first stage of the disease, the only systemic manifestation of the infection.

[The clinical picture of Fuch's heterochromic cyclitis]. / Fuchsova heterochromická cyklitida v klinickém obraze.

The authors are presenting their experience with the diagnosis and treatment of Fuchs' heterochromic cyclitis. They followed-up 13 patients with this disease for 0.5-3 years. Most often the patients were sent to the clinic with the diagnosis of recurrent anterior uveitis not responding to the treatment with corticosteroids and mydriatics. Patients underwent numerous investigations including neurological, internal and rheumatological examinations. Antibodies against EBV, HSV and CMV were detected. The examination of humoral immunity and HLA was done. The authors describe the ophthalmological findings, the course of the disease and the treatment. They did not find any correlation in the laboratory investigations and the course of the disease, the diagnosis is based on the clinical picture. They point out the advantage of the small incision in the extracapsular extraction of cataract in these patients.

[Diagnostic problems in uveitis]. / Problematika diagnostiky uveitid.

The authors examined and followed up for two years 102 subjects who were referred to the First Ophthalmological Clinic of the First Medical Faculty, Charles University, Prague on account of idiopathic uveitis. They used a wide range of examination methods by means of which they were able to differentiate idiopathic uveitis from anterior uveitis with the presence of HLA B27, Fuchs disease and Eales disease. A quarter of the patients suffered from general disease, internal or neurological, where uveitis can be one of the symptoms. This disease was not diagnosed at the time of exacerbation of uveitis. The authors describe a series of examination methods and their contribution to the assessment of the correct diagnosis. They discuss the development of views regarding the diagnosis of idiopathic uveitis and views on the treatment of this disease.

[Autoimmune etiology of endogenous uveitis]. / Nekteré poznámky k autoimunitní etiologii endogenních uveitid.

The authors presents a review of some findings on the basis of which it is possible to classify uveitis, retinitis and choroiditis already at the time of its onset, and in particular subsequently, as an autoimmune disease. They consider this review an adequate basis for immunosuppression therapy of uveitis at the very onset, although they do not analyze it in the submitted paper.

[Immunologic profile in patients with acute anterior uveitis]. / Imunologický profil nemocných akutní prední uveitidou.

The authors investigated 52 patients (22 men and 30 women) with acute anterior uveitis where they ruled out systemic autoimmune disease, metabolic disease and focal or chronic infection. At the time of the infection the patients had not been treated for several months by any immunosuppressive treatment. The authors investigated in these patients serum concentrations of immunoglobulins G, A and M, the concentration of the C3 component of complement and the concentration of circulating immune complexes. Before the onset of therapy they investigated the response to antigens of the Immunoskin test. They assessed also the ratio of transplantation antigens class I by the microlymphocytotoxic test. They compared furthermore immunological indicators in subjects with a first attack and relapse of the disease and in groups, classified by the severity of the inflammatory symptoms. The authors detected significantly more frequently (p = 0.0005) the incidence of HLA-B27 antigen. Those where it was present were more frequently affected with a severe inflammation, as compared with subjects who did not have this phenotype (p less than 0.04). The relapse of the disease was more frequent in women (p = 0.1). The immunological laboratory findings did not differ in the first attacks and relapses of the disease, differences were, however, found in groups which differed as to the severity of inflammatory symptoms. In these groups the response rate to tests of skin sensitivity differed also. Based on these findings the authors assume that the ratio of immune processes in the development of acute idiopathic anterior uveitis cannot be ruled out.