Association of 17p loss with late-stage or refractory disease in hematologic malignancy.

Twenty-five patients with loss of part or all of 17p were selected from 701 patients with hematologic malignancies karyotyped either at diagnosis and/or at relapse and/or in refractory disease. Loss of 17p resulted from partial arm deletion (eight cases), unbalanced translocation (12 cases), i(17)(q10)(five cases) or monosomy 17 (four cases). In three cases, both 17ps were missing; in one case, two sublines independently acquired loss of 17p. In eight cases, loss of 17p was confirmed as a secondary change. The karyotypes generally were complex, with an average of 4.0 structurally abnormal chromosomes in the simplest lines showing 17p loss. The incidence at diagnosis was acute lymphoblastic leukemia (ALL) 2.2%, acute myeloid leukemia (AML) 2.4%, and myelodysplastic syndrome (MDS) 3.4%. The incidence in relapse and refractory disease was ALL 8.9%, AML 3.3%, and MDS 6.3%. The increased incidence of 17p loss in relapse and refractory disease was statistically significant (p < 0.05). Loss of 17p appears to be a feature of late-stage or resistant disease in hematologic malignancy.

Flunarizine for treatment of partial seizures: results of a concentration-controlled trial.

The National Institutes of Health sponsored a randomized, double-blind, multicenter, placebo-controlled trial of flunarizine (FNR) in epileptic patients receiving concomitant phenytoin (PHT) or carbamazepine (CBZ). Because of FNR's long half-life (up to 7 weeks), a parallel rather than crossover design was used. Each patient received an individualized loading dose and maintenance dosage targeted at a 60-ng/ml plasma FNR concentration. Of 93 patients randomized, 92 provided seizure data for the full 25-week treatment period; one placebo-treated patient dropped out for personal reasons. Fifty-four patients received CBZ only, nine received PHT only, and 30 received both CBZ and PHT. Eighty-seven patients had a history of complex partial seizures, and 60 had secondarily generalized seizures. Eight patients discontinued FNR prematurely, all because of adverse neurologic or psychiatric signs or symptoms; depression was the specific cause in three cases. Calculated maintenance dosages, based on single-dose pharmacokinetic profiles, ranged from 7 to 138 mg/day (mean, 40 mg/day). Plasma FNR concentrations generally exceeded the target, with the highest concentrations observed immediately after loading; excluding the first three treatment weeks and all concentrations after a FNR dosage change, the median plasma FNR concentration was 71.7 ng/ml. The percent reduction from baseline seizure rate was statistically greater (p = 0.002) in the FNR-treated group (mean, 24.4%) than in the placebo-treated group (mean, 5.7%).

Partial NADH dehydrogenase defect presenting as spastic cerebral palsy.

Mitochondrial myopathies are heterogeneous disorders. They may present at any age with a variable clinical course. We report a 6-year-old boy presenting as spastic cerebral palsy for 4 years, then athetotic movements and loss of milestones. He was eventually found to have NADH dehydrogenase deficiency.

Abnormal responses to cold stress in Charcot-Marie-Tooth I syndrome.

In Charcot-Marie-Tooth syndrome (CMT, Hereditary Motor Sensory Neuropathy), patient complaints of cold intolerance are common but their peripheral responses to cold have not been documented. Using digital plethysmography, a simple test of vascular reactivity with 1 minute cold stress, 20 unrelated adult CMT patients showed a significantly increased average heart rate and decreased average arterial oxygen saturation following cold when compared to 50 age-matched normal controls. There did not appear to be a unique or characteristic CMT vascular reaction to cold stress in CMT patients because their abnormal peripheral vascular responses were variable. Variability in CMT neuropathic responses to cold is consistent with the known irregular segmental demyelination of CMT peripheral nerves as well as abnormal CMT sweating patterns. Though understanding the precise patterns of CMT patient peripheral nerve disturbances remains difficult, awareness of CMT patient's abnormal responses to cold may facilitate CMT patient care and rehabilitation.

Familial adrenal insufficiency, achalasia, alacrima, peripheral neuropathy, microcephaly, normal plasma very long chain fatty acids, and normal muscle mitochondrial respiratory chain enzymes.

Adrenal insufficiency has been associated with adrenoleukodystrophy and adrenomyeloneuropathy. In these diseases, plasma very long chain fatty acids are elevated. Peripheral neuropathy is frequently seen in adults with adrenomyeloneuropathy. We encountered two first cousins with adrenal insufficiency, who also developed peripheral neuropathy, achalasia, alacrima, and microcephaly. However, plasma very long chain fatty acids, pipecolic acid, phytanic acid, and cranial computed tomographic scan were normal. Muscle mitochondrial respiratory chain enzymes were also normal. This syndrome of adrenal insufficiency, achalasia, alacrima, microcephaly, and peripheral neuropathy is different from either adrenomyeloneuropathy or adrenoleukodystrophy.

A hypotonic infant with complete deficiencies of acid maltase and debrancher enzyme.

Infantile acid maltase deficiency is an autosomal recessive disease that invariably leads to death in the first 2 years of life. Debrancher deficiency, also an autosomal recessive disease, however, carriers a slowly progressive course. We report a hypotonic infant with a typical clinical course of infantile acid maltase deficiency in whom biochemical investigation revealed complete deficiencies of both acid maltase and debrancher enzyme.

Arachidonic fatty acid in red blood cell membranes, lymphocytes, and cultured skin fibroblasts of dominant Charcot-Marie-Tooth syndrome.

Altered proportions of long-chain unsaturated n - 6 fatty acids (FA) in plasma and myelin of the heredodegenerative peripheral neuropathy, Charcot-Marie-Tooth syndrome (CMT), may implicate FA metabolism in the pathogenesis of CMT demyelination. A significant relationship between low plasma values of the polyunsaturated n - 6 FA, arachidonic acid, and an increased amount of prostaglandin-mediated immune responses had suggested the possibility of immune system metabolic usage of these n - 6 FA rather than an inherited FA enzyme defect. This relationship between peripheral immunostimulation and altered FA was documented repeatedly in CMT patients. Increased and cyclic lymphocyte activation expressions were measured at the same time as low amounts of plasma arachidonic acid, which is the FA precursor of prostaglandin immunoregulatory agents. An autoimmune process with possible enhanced formation of the n - 6 immune prostenoid agents in CMT had also been suggested by increased class II antigen expression on CMT sural nerves. Here, normal proportions of total FA in cultured CMT skin fibroblasts diminishes a notion of hereditary defects in CMT fatty acid metabolism. In addition, a significant depletion of the key arachidonic acid in lipid stores of CMT red blood cell membranes with elevated values of this FA in functional CMT lymphocytes, compared to controls, support the concept in CMT patients of a metabolic diversion of n - 6 FA, particularly arachidonic acid, from tissue stores for immunoregulatory prostenoid agent formation.

Circulating cytotoxic immune components in dominant Charcot-Marie-Tooth syndrome.

Activated T cells, measured repeatedly in the demyelinating peripheral neuropathy, Charcot-Marie-Tooth syndrome (CMT; hereditary motor sensory neuropathy), might participate in myelin loss by a destructive inflammatory autoimmune process. To explore this possibility, plasma proportions of hydroxyleukotrienes, their fatty acid precursor, arachidonic acid, and lymphocyte epitopes associated with immune cell activation expression were measured in 18 adults with dominant, Type I CMT. Compared to age-matched normal controls, CMT I patients showed eicosanoid-linked immunoactivation by an elevated content of 12-hydroxy-eicosatetraenoic acid (12-HETE) in parallel with a decreased plasma percentage of its fatty acid precursor, arachidonic acid. CMT patients also had increased numbers of peripheral lymphocytes expressing activation-related epitopes, CD25+, CD26+, CD4+, and CD4/CD45RO+ primed memory cells, with enhanced CD8+ cytotoxic cells and soluble CD8 protein content. Therefore, endogenously stimulated CMT I lymphocytes include functional cytotoxic cells which appear to deplete the plasma fatty acid precursor of prostenoid agents during the secretion of potentially destructive cytokines.

Renal mechanism of trimethoprim-induced hyperkalemia.

OBJECTIVES: 1) To determine the incidence and severity of hyperkalemia during trimethoprim therapy. 2) To test the hypothesis that trimethoprim inhibits renal potassium excretion by blocking sodium channels in the mammalian distal nephron. PATIENTS: Thirty consecutive patients who were treated with trimethoprim-containing drugs. All patients included in the study had the acquired immunodeficiency syndrome (AIDS). EXPERIMENTAL ANIMALS: Thirty-nine male Sprague-Dawley rats receiving normal rat chow and tap water (allowed free access). INTERVENTION: Humans: high dose (20 mg/kg per day) of trimethoprim therapy. Rats: trimethoprim (9.6 mg/h per kg body weight) was infused intravenously or into the renal distal tubules (1 mmol/L). MEASUREMENTS: Humans: Serum and urine electrolyte levels, serum creatinine, renin, aldosterone, and cortisol levels were measured, and the transtubular potassium gradient was calculated. Rats: The effects of trimethoprim infusion on urinary sodium, chloride, and potassium concentration and urine volume were measured. Sodium, chloride, potassium, and inulin concentrations were measured in fluid samples obtained from kidney distal tubules. The voltage across the wall of the distal tubule was measured. RESULTS: Humans: Trimethoprim increased the serum potassium concentration by 0.6 mmol/L (95% Cl, 0.29 to 0.95 mmol/L) despite normal adrenocortical function and glomerular filtration rate. Serum potassium levels greater than 5 mmol/L were observed during trimethoprim treatment in 15 of 30 patients. Rats: Intravenous trimethoprim inhibited renal potassium excretion by 40% (Cl, 21% to 60%) and increased renal sodium excretion by 46% (Cl, 9% to 83%). Trimethoprim (1 mmol/L) in tubule fluid inhibited distal tubule potassium secretion by 59% (Cl, 26% to 92%) and depolarized the lumen-negative transepithelial voltage by 66% (Cl, 46% to 85%). CONCLUSIONS: Trimethoprim (an organic cation) acts like amiloride and blocks apical membrane sodium channels in the mammalian distal nephron. As a consequence, the transepithelial voltage is reduced and potassium secretion is inhibited. Decreased renal potassium excretion secondary to these direct effects on kidney tubules leads to hyperkalemia in a substantial number of patients being treated with trimethoprim-containing drugs.

Resetting of tubuloglomerular feedback by interrupting early distal flow.

Cell-cell contact between the macula densa and the glomerular arterioles is is thought to provide the information pathway for the tubuloglomerular feedback (TGF) mechanism. When concentrations of sodium and chloride in the macula densa segment are increased, a signal is transmitted through the extraglomerular mesangium to contract the afferent arteriole. In addition, some observers have described a second region of contact between a later part of the distal tubule and the afferent arteriole of the same nephron. In this region the connecting tubule (CNT), and sometimes nerves that make contact with the cells of this CNT, were found. This arrangement gives another potential tubular segment, besides the macula densa plaque, in which the composition of tubular fluid may regulate glomerular dynamics. The present study was designed to investigate whether interrupting flow in the distal tubule downstream from the macula densa would influence the TGF mechanism. TGF was examined in rats by orthograde microperfusion, before and after blockade of the distal nephron with castor oil. Two variables were measured: maximum decrease in stop-flow pressure (delta Psf), and perfusion rate which elicits half-maximal decrease in delta Psf (V1/2). The fluid arriving at the blocking point was collected into a micro-pipette. The results show a significant increase in V1/2 from 19 to 25 nl min-1 after 30 min of blockade. In conclusion the results support a role of the distal nephron in the control of the TGF mechanism.

Acute chemical pancreatitis associated with carbamazepine intoxication.

A 5-year-old mentally retarded child developed laboratory evidence of pancreatitis during accidental acute carbamazepine (CBZ) intoxication. He had been seizure-free with CBZ for 4 years for a seizure disorder with no obvious toxicity. CBZ had been discontinued 5 months before he was admitted to the hospital. After he accidentally ingested a CBZ overdose, he was found vomiting and lethargic. Serum amylase and lipase levels were increased for several days. With supportive treatment and no CBZ, he recovered and serum amylase and lipase levels returned to normal. No other causes of pancreatitis were identified. Therefore, most likely the chemical pancreatitis was associated with the acute CBZ intoxication.

Clinical imitators of infantile spasms.

We report 53 infants who by clinical history were thought to have infantile spasms but who video-electroencephalograms showed were having other episodes that closely mimicked infantile spasms. Nine patients had other types of seizures. Forty-five patients had episodic symptoms that were not seizures: 11 patients had spasticity, four had gastroesophageal reflux, and the other patients had nonepileptic myoclonus, including 19 patients with benign neonatal sleep myoclonus. Three patients had more than one type of symptom. Infantile spasms imitators occurred in neurologically normal or abnormal infants, in patients with normal or abnormal interictal electroencephalograms, and in patients who also had previous or current infantile spasms. Differentiation of these episodes from infantile spasms prevented the initiation or continuation of anticonvulsant treatment appropriate for infantile spasms but inappropriate for these other behaviors.

Luminal influences on potassium secretion: chloride, sodium, and thiazide diuretics.

In the presence of Cl-, K+ secretion by the distal tubule saturates with increasing luminal Na+ concentration. Apparent maximal K+ secretion is attained with luminal Na+ concentrations of 40 mM. The results of the present study show that lowering the Cl- concentration of luminal fluid can increase the level of Na(+)-stimulated K+ secretion beyond the maximal level attained in the presence of Cl-. The effect of lowering luminal Cl- concentration to less than 10 mM on K+ secretion is greater with higher Na+ concentration. Under these conditions, chlorothiazide decreases K+ secretion. When chlorothiazide is present, changing the Na+ concentration does not affect K+ secretion. Because in rats a thiazide effect is attributed primarily to the distal convoluted tubule (DCT), we postulate that it is primarily DCT cells that increase K+ secretion when Na+ concentration is raised in the presence of low luminal Cl- concentration. We propose that the rat DCT cells have both an absorptive Na(+)-Cl- cotransport mechanism and a secretory K(+)-Cl- cotransport mechanism in the luminal membrane that can mediate the apparent exchange of Na+ for K+.

Active potassium absorption by the renal distal tubule.

Maintenance of potassium homeostasis during potassium depletion appears to involve an active potassium absorptive mechanism in the distal nephron. Direct demonstration of such a pathway in the distal tubule of the rat has been lacking. The purpose of the current study was to examine the hypothesis that an ATP-dependent active transport mechanism plays a role in potassium absorption by the rat distal tubule. We utilized in vivo microperfusion techniques in Sprague-Dawley rats maintained on a regular diet of low-potassium diet for 3-4 wk. The effect of a selective inhibitor of the gastric H-K-adenosinetriphosphatase (ATPase) (Sch 28080, 0.1 mM) was tested in distal tubules of both groups of rats. Distal tubules of normal rats secreted potassium. Sch 28080 had no effect on this net potassium flux. In contrast, distal tubules of potassium-deficient rats absorbed potassium. Sch 28080 abolished this potassium absorption and produced a small hyperpolarization of the lumen-negative transepithelial voltage (VTE). The change in VTE can be explained by a concomitant increase in potassium concentration in the late distal tubule. These results are consistent with the presence of an H-K-ATPase in the distal tubule of potassium-deficient rats.

Expression of Schwann cell and peripheral T-cell activation epitopes in hereditary motor and sensory neuropathy.

To evaluate possible immune-mediated mechanisms in hereditary motor and sensory neuropathy (HMSN-I, Charcot-Marie-Tooth syndrome), we examined class II major histocompatibility complex antigen expression (MHC-II, HLA-DR) in Schwann cells and peripheral lymphocyte T-cell (Ta1, CD26) activation in five unrelated adults with HMSN-I. Evidence of increased activation expression was found in both compartments but the pattern did not suggest a general state of hyperimmunity or appear related to clinical characteristics of HMSN. Significantly increased CD26+ T-cell activation and greater than normal fluctuation of values occurred intermittently in sequential tests of eight HMSN patients and at single time points in 24 others. The combined data, consistent with repeated stimulations of an immune reaction under normal feedback control, suggest that HMSN-I expresses some characteristics also found in autoimmune polyneuropathies.

Unusual variants of infantile spasms.

During evaluation of video-electroencephalograms (EEGs) performed in our laboratory, we identified 11 patients who had unusual repetitive movements that appeared to be variants of infantile spasms. Movements included yawning, facial grimacing, eye movements, and transient focal motor activity. These symptoms coincided with generalized attenuation, slow-wave transients, or other EEG ictal changes characteristic of infantile spasms. The background EEGs showed true or modified hypsarrhythmia. This series of patients shows that infantile spasms may be extremely subtle and clinically atypical. Patients who have these variants may or may not also have typical infantile spasms. In some patients, the seizures appear to be time-related or medication-induced modifications of more typical infantile spasms.

Adaptation of distal convoluted tubule of rats. II. Effects of chronic thiazide infusion.

Mammalian distal tubules adapt structurally and functionally when NaCl concentration in tubule fluid is altered chronically. These experiments were designed to test the hypothesis that chronic administration of hydrochlorothiazide (HCTZ), a drug that blocks Na and Cl uptake across apical membranes of rat distal tubule cells, would reduce intrinsic transport capacity of distal tubules and reduce the number of thiazide-sensitive transporters. Osmotic pumps were implanted into rats to deliver 3.75 mg/day HCTZ or vehicle for 10-14 days. All animals were offered a solution containing 0.8% NaCl and 0.1% KCl as drinking fluid. Free-flow micropuncture after 10-14 days indicated that Na and Cl delivery to distal tubule was not significantly different in HCTZ- and vehicle-treated animals. Microperfusion in vivo with an artificial interstitial solution, with no thiazide, indicated that 10-14 days of HCTZ infusion did reduce Na transport capacity of distal tubules from 390 +/- 32 to 203 +/- 24 pmol/min (P less than 0.01). In contrast, the number of thiazide-sensitive NaCl transporters, determined as high-affinity receptors for [3H]metolazone in renal cortical membranes, was higher in HCTZ group than in controls (2.2 +/- 0.4 vs. 1.0 +/- 0.1 pmol/mg protein, P less than 0.01). These data support the hypothesis that chronic blockade of NaCl entry across apical membranes of distal tubule cells reduces NaCl transport capacity, an effect that occurs despite an increase in the number of thiazide receptors. They indicate that thiazide receptor binding studies should be interpreted in combination with direct functional measurements.

Seizures in series: similarities between seizures of the west and Lennox-Gastaut syndromes.

We observed seizures resembling infantile spasms in patients with Lennox-Gastaut syndrome (LGS). Infantile spasms, the type of seizures that occurs in patients who have West syndrome, have been well characterized by video-EEG studies and typically occur as a series of sudden generalized flexor or extensor jerks. The seizure types that occur in LGS have not been as clearly delineated. Some patients with West syndrome (WS) in early infancy later develop LGS. Using intensive video-EEG monitoring, we evaluated 14 LGS patients who had seizures that occurred in series. Clinically, the seizures greatly resembled infantile spasms, and the ictal EEG changes were identical to those that occur with infantile spasms. These findings expand the number of features known to be shared by these two syndromes and strengthen the hypothesis that the two syndromes represent age-related manifestations of similar epileptogenic processes.

Simultaneous infantile spasms and partial seizures.

We report 11 infants with infantile spasms who had partial seizures that occurred concurrently with the infantile spasms. We studied this phenomenon with time-locked video electroencephalography. The partial seizures began before the infantile spasms and continued after one or more infantile spasms in seven patients. An infantile spasm occurred at the beginning of the partial seizure in five patients. (One patient had both seizure types simultaneously.) The clinical descriptions of these combinations of seizures were confusing, since they did not match known seizure types. The genesis of these seizures may involve an interaction between processes of focal cortical epileptogenesis (partial seizures) and brain-stem synchronization (infantile spasms).

Recovery of cognition from persistent vegetative state in a child with normal somatosensory evoked potentials.

The absence of bilateral early cortical SEPs in a PVS due to nontraumatic coma is usually associated with failure to recover cognition or awareness, although rarely patients with bilaterally absent cortical SEPs in posttraumatic PVS may regain cognition. On the other hand, normal cortical SEPs in nontraumatic coma may be related to favorable outcomes as shown in this patient and other reports. Our patient is unique in that he had had serial normal SEPs, was in a PVS for 7 1/2 months, and recovered cognition, but not without cost in terms of damage to intellectual capability. Further long-term clinical follow-up studies to correlate clinical outcome with serial SEP data may be indicated.