Serum osteopontin in patients with lung cancer and chronic obstructive pulmonary disease: does the co-existence make the difference?

BACKGROUND: Osteopontin (OPN) is involved in cancer development and metastasis. Increased sputum OPN was detected in chronic obstructive pulmonary disease (COPD). METHODS: We evaluated serum OPN levels in patients with lung cancer (LC) and/or COPD and aimed to determine OPN prognostic performance in 1-year mortality in LC and also its diagnostic performance in LC among COPD patients. We recruited 167 LC patients, 85 with concomitant COPD. 28 COPD patients served as control group. RESULTS: OPN levels were higher in LC compared to COPD alone (P=0.017) and higher in COPD and LC compared to COPD alone (P=0.031). No difference was observed in OPN levels between LC and COPD vs. LC without COPD (P=0.171). Serum OPN ≥50.3 ng/mL was an independent predictor of 1-year mortality in LC. CONCLUSIONS: OPN levels ≥35 ng/mL could predict the presence of LC among COPD patients. In patients with LC and/or COPD, LC is the major determinant for serum OPN. Serum OPN might be a promising prognostic biomarker of LC and a diagnostic biomarker of LC among COPD patients.

Exhaled breath temperature in optimally treated asthmatics: severity and underlying mechanisms.

INTRODUCTION: Increased vascularity may lead to loss of heat in the airways and may modulate exhaled breath temperature (EBT). Increased EBT has been associated with uncontrolled asthma. AIM: We wanted to determine whether the measurement of EBT in optimally treated asthmatic patients is influenced by the increased vascular permeability and whether Vascular endothelial growth factor (VEGF) is implicated in the above process. Furthermore, to assess the impact of asthma severity on EBT values. The diagnostic performance of EBT for the identification of inflammatory profiles in induced sputum was also assessed. METHODS: 88 stable asthmatic patients optimally treated for at least 6 months were studied (46 with Severe Refractory Asthma, SRA). EBT was measured with the X-halo device. All patients underwent spirometry, sputum induction for the measurement of % inflammatory cells and for the assessment of both VEGF and albumin in sputum supernatant. The airway vascular permeability index was calculated as the ratio of albumin concentrations in induced sputum and serum. RESULTS: EBT (°C) was significantly higher in patients with SRA compared to those with mild to moderate asthma (median IQR 34.2 [32.4-34.6] versus 31.8 [26.3-34.1], p = 0.001). EBT was significantly associated with VEGF levels in sputum supernatant, while SRA was recognized as a significant co-variate. No other significant associations were observed. Finally, in ROC analysis, the diagnostic performance of EBT for the pure eosinophilic or/and neutrophilic profile did not reach statistical significance. CONCLUSION: EBT is increasing in severe asthma and is significantly modulated by VEGF levels. Despite the above results its performance for predicting cellular profiles is of limited value.

Serum periostin in patients hospitalized for COPD exacerbations.

Serum periostin has been proposed as a surrogate biomarker of Th2 inflammatory response in patients with asthma, but its predictive role in hospitalized patients with COPD has not been evaluated. The aim of the present observational prospective cohort study was to evaluate the possible role of serum periostin as predictor of outcome in COPD patients hospitalized for AECOPD. Serum periostin was measured on admission and at discharge in patients admitted to the hospital for a COPD exacerbation. Patients were followed-up for 1year for future exacerbations, hospitalizations and mortality. 155 consecutive patients admitted to the hospital for AECOPD were included to the study. Periostin levels on admission were elevated compared to discharge [34.7 (25.2-52.2) vs. 25.9 (17.4-41.0) ng/mL, p=0.003], but serum periostin levels did not differ between patients with or without prolonged hospitalization, or those who required non-invasive ventilation, intubation, or died during hospitalization. Frequent exacerbators had higher serum periostin levels at the time of discharge compared to non-frequent exacerbators [37.9 (26.6, 64.5) vs. 23.9 (16.2, 37.9), p<0.001]. Periostin levels above the median value (25ng/mL) were not related to the time of next exacerbation, time of next COPD hospitalization, (p=0.858) or time to death. The role of serum periostin levels as a predictive biomarker of future risk in hospitalized patients with COPD is of limited value.

Activin A and follistatin in patients with asthma. Does severity make the difference?

BACKGROUND AND OBJECTIVE: Activin A is a pleiotropic cytokine holding a fundamental role in inflammation and tissue remodelling. Follistatin can modulate the bioactivity of activin. We aimed to measure activin A and follistatin in sputum supernatants and bronchoalveolar lavage (BAL) of asthmatic patients and to determine the possible associations with severity as well as with inflammatory and remodelling indices. METHODS: A total of 58 asthmatic patients (33 with severe refractory asthma (SRA)) and 10 healthy controls underwent sputum induction for % cells, activin A, follistatin, eosinophilic cationic protein (ECP), transforming growth factor beta 1 (TGF-ß1), IL-13 and IL-8 measurements. In 22 asthmatic patients, BAL and bronchial biopsies were also performed for the assessment of the above-mentioned variables, measurement of remodelling indices and immunostaining for different activin A receptors. RESULTS: Sputum activin A (pg/mL) was higher in patients with SRA (median (interquartile ranges): 76 (33-185)) compared to mild-to-moderate asthma (44 (18-84); P = 0.005), whereas follistatin did not differ between the two groups. BAL activin A (pg/mL) was higher in patients with SRA compared to those with mild-to-moderate disease. A significant association was observed between activin A and TGF-ß1, eosinophils in sputum and/or in BAL, while reticular basement membrane (RBM) thickness was significantly associated with BAL activin levels only. No difference in immunostaining for activin receptor type IB was observed between patients with SRA and those with mild-to-moderate asthma. CONCLUSION: Sputum and BAL levels of activin A are higher in SRA. The association of activin A with TGF-ß1, eosinophils and RBM thickness may indicate a role of this cytokine in the inflammatory and remodelling process in SRA.

Predictors of future exacerbation risk in patients with asthma.

OBJECTIVES: Although modern treatment of asthma improves asthma control, some patients still experience exacerbations. The aim of the present study was to detect predictors of asthmatic exacerbations Methods: We included patients with asthma followed up in asthma clinics of 2 tertiary University hospitals. Demographic and functional characteristics, levels of exhaled NO, and inflammatory biomarkers (IL-13, ΕCP και IL-8) and cell counts in induced sputum were recorded at baseline. Measurements were performed with the patients in stability and were considered as their personal best. Patients received optimal treatment with good compliance and were followed up for 1 year for asthma exacerbations occurrence. Evaluation of the effect of recorded parameters on asthma exacerbations was performed with univariate and multivariate Poisson regression analysis. RESULTS: 171 patients (118 female) with bronchial asthma (mean age 51.6 ± 13.2 years) were included in the study. The mean number of exacerbations in 1 year of follow up was 0.4 ± 0.8 while the majority of patients (71.9%) did not experience any exacerbation. In multivariate Poisson Regression analysis only 3 characteristics were predictors of future exacerbations: FEV1 [IRR(95% CI)], [0.970(0.954-0.987)], p = 0.001, high BMI [1.078(1.030-1.129)], p = 0.001, and the need for permanent treatment with oral corticosteroids for asthma control maintenance [2.542(1.083-5.964)], p = 0.032 CONCLUSION: Optimal guideline-based asthma management results in minimal occurrence of exacerbations in the majority of patients. Predictors of exacerbations are low FEV1 levels in stability, high BMI and the need for permanent treatment with oral corticosteroids.

Increased levels of osteopontin in sputum supernatant in patients with COPD.

BACKGROUND: Osteopontin (OPN) is a phosphorylated acidic glycoprotein that can function as both an extracellular matrix molecule and a cytokine. Published data support that OPN is upregulated in surgical lung tissue samples of patients with COPD. The aim of this study was to determine the levels of OPN in sputum supernatants of patients with COPD and to investigate possible associations with mediators and cells involved in the inflammatory and remodeling process as well as with the extent of emphysema. METHODS: Seventy-seven patients with COPD and 40 healthy subjects (20 smokers) were studied. All subjects underwent lung function tests, sputum induction for cell count identification, and OPN, transforming growth factor-ß1, matrix metalloproteinase (MMP)-2, IL-8, and leukotriene-4 measurement in sputum supernatants. High-resolution CT (HRCT) scan of the chest was performed for quantification of emphysema. RESULTS: OPN levels (pg/mL) were significantly higher in patients with COPD compared with healthy smokers and nonsmokers (median [interquartile range], 1,340 [601, 6,227] vs 101 [77, 110] vs 68 [50, 89], respectively; P < .001). Regression analysis showed a significant association between OPN and sputum neutrophils, IL-8, MMP-2, and the extent of emphysema. The associations previously listed were not observed in healthy subjects. CONCLUSIONS: OPN levels are higher in patients with COPD compared with healthy subjects. OPN may play a role in the neutrophilic inflammation and in the pathogenesis of emphysema.

Osmolal gap in hemodialyzed uremic patients.

Osmolality is an expression of the number of particles in a given weight of solvent (mOsm). Measured osmolality is determined by the osmometer, and calculated osmolality is estimated by 2xNa + UN/2.8 + glucose/18. The difference between measured and calculated osmolality is the osmolal gap. The purpose of the present study is to determine the measured and the calculated osmolality and the osmolal gap in hemodialyzed uremic patients, pre- and post-hemodialysis (HD). In 24 uremic patients under regular HD, blood samples pre- and post-HD were collected, and serum osmolality measured (osmometer) and calculated (2xNa + UN/2.8 + glucose/18) and the osmolal gap (measured-calculated osmolality) were determined. Also, the same parameters were determined in 22 healthy subjects (control). According to our findings, the measured osmolality in patients is significantly higher pre- and post-HD in comparison to that of controls, but post-HD is significantly lower than pre-HD. Also, calculated osmolality is significantly higher pre- and post-HD in comparison to that of controls, but the value post-HD is significantly lower than the pre-HD. The osmolal gap of patients pre-HD (11 ± 2.08) and post-HD (7.29 ± 1.94) is significantly higher (P < 0.001) in comparison to that of controls (3.18 ± 1.46); also, the value post-HD is significantly decreased in comparison to the value pre-HD (P < 0.001). Uremic hemodialyzed patients present high measured and calculated osmolality pre-HD that remains high post-HD in comparison to that of controls in spite of the significant decrease post-HD in comparison to that of pre-HD. Also, the osmolal gap is high pre-HD and, in spite of the decrease, remains high post-HD. In comparison to that of controls, the high osmolal gap indirectly indicates the presence of unidentified endogenous osmoles in the serum of uremic patients which partly are removed during HD.

Hemoglobin, erythropoietin and systemic inflammation in exacerbations of chronic obstructive pulmonary disease.

BACKGROUND: Systemic inflammation may represent a possible cause of anemia. Previous data support that anemic patients with COPD present high erythropoietin (EPO) levels, suggestive of EPO resistance, possibly mediated through inflammatory mechanisms. OBJECTIVES: We aimed to determine whether systemic inflammation, which is usually up-regulated during exacerbations of COPD (ECOPD) is associated with low hemoglobin levels expressing erythropoietin resistance. METHODS: Hemoglobin (Hb), EPO and serum biomarkers of systemic inflammation [CRP, TNF-α, fibrinogen and IL-6] were assessed at three time points (admission, resolution and stable phases) in a selected cohort of 93 COPD patients. RESULTS: Hemoglobin levels were significantly lower on admission compared to resolution and stable phases (median 12.1 g/dl [interquartile ranges 11.2-12.7], vs 13.5 [12.4-14.3] vs 13.4 [12.7-14.08], respectively p=0.002), whereas EPO was significantly higher on admission compared to resolution and stable phases. A negative association between Hb and IL-6 and a positive association between EPO and IL-6 were observed only during the acute phase of exacerbation. EPO and Hb were negatively associated during the acute phase, whereas they were positively associated during discharge and stable phase. CONCLUSIONS: In this observational study we have shown that during admission for ECOPD Hb levels are decreased and EPO levels are increased. We have also identified a negative association between Hb and EPO. The above association is mainly related to increased IL-6 levels, indicating a possible EPO resistance through the mechanism of increased systemic inflammatory process.

Body mass index is associated with leukotriene inflammation in asthmatics.

BACKGROUND: Obesity and asthma are characterized by the presence of inflammation. Leptin and adiponectin are circulating hormones produced by adipose tissue that regulate several metabolic and inflammatory functions. We aimed to determine whether obesity influences asthmatic inflammation as well as the contribution of leptin or/and adiponectin to a possible linkage between asthmatic and obesity-related inflammation. MATERIALS AND METHODS: One hundred patients with asthma and 60 healthy controls were studied. Subjects who had a comorbid illness that could interfere with the proposed tests were excluded. All subjects were divided into three groups (normal range, pre-obese, obese) according to the criteria of the current WHO international classification for body mass index (BMI). Possible associations between variables expressing airway inflammation, bronchial hyper-responsiveness, systemic inflammation and obesity, as assessed by BMI, were evaluated. Leptin and adiponectin were also measured and were associated with asthma airway and systemic inflammatory variables to elucidate possible associations. RESULTS: Obese patients had significant higher values of LTE(4) /creatinine in urine compared with pre-obese and normal range ones. In a linear regression model, the only significant associations were those between BMI and LTE(4) /creatinine in urine. Using the same model, log leptin and log adiponectin presented positive and negative associations, respectively with LTE(4) /creatinine in urine. No other significant associations were observed in both patients and healthy subjects. CONCLUSIONS: In a selected cohort of asthmatic patients, obesity is significantly associated with increased urinary leukotriene levels. Alterations of leptin/adiponectin balance may be related to the presence of leukotriene inflammation in obese asthmatic patients.

Plasma leptin and adiponectin in COPD exacerbations: associations with inflammatory biomarkers.

BACKGROUND: Various systemic inflammatory markers have been evaluated for their value in acute exacerbations of chronic obstructive pulmonary disease (COPD). Leptin and adiponectin have been linked to acute exacerbations and stable COPD. OBJECTIVES: To assess plasma leptin, adiponectin and their ratio in acute exacerbations of COPD and to study possible associations with inflammatory biomarkers. METHODS: Plasma leptin, adiponectin and their ratio (L/A) and serum biomarkers of systemic inflammation C-reactive protein (CRP), Tumor necrosis factor alpha (TNF-alpha) and interleukin-6 (IL-6) were assessed at three time points (admission, resolution and stable phase - 8 weeks after resolution) in a selected cohort of 63 COPD patients hospitalized for acute exacerbations. Subjects with comorbidities related to adipose tissue hormones were meticulously excluded. MEASUREMENTS AND MAIN RESULTS: All systemic inflammatory biomarkers, leptin and L/A ratio were elevated during admission compared to resolution and stable phase (mean L/A ratio 2.6 vs. 1.57 vs. 1.22, respectively; p<0.0001), whereas adiponectin was elevated at resolution compared to admission. Log leptin, adiponectin and L/A ratio were significantly associated with variables of systemic inflammation, after proper adjustments, both on admission and in stable condition. In stepwise multiple linear regression models, IL-6 and TNF-alpha present the most significant associations with leptin, adiponectin and their ratio. CONCLUSIONS: Our data suggest that both leptin and adiponectin are associated with the systemic inflammatory process during exacerbations of COPD. The most significant associations seem to be those with IL-6 and TNF-alpha.

Predictive implications of bone turnover markers after palliative treatment with (186)Re-HEDP in hormone-refractory prostate cancer patients with painful osseous metastases.

PURPOSE: To prospectively evaluate the predictive value of various bone formation and resorption markers in patients with bone metastases from prostate cancer after palliative treatment with (186)Re-1,1-hydroxyethylidene diphosphonate ((186)Re-HEDP). METHODS: Included in the study were 36 men with prostate cancer, suffering from painful osseous metastases and treated with (186)Re-HEDP. None had received any treatment that would have interfered with bone metabolism before (186)Re-HEDP treatment or throughout the follow-up period. For each patient, pretreatment and posttreatment serum levels of osteocalcin (OC), bone alkaline phosphatase (BALP), aminoterminal (PINP) and carboxyterminal (PICP) propeptides of type I collagen, amino-terminal (NTx) and carboxyterminal (CTx) telopeptides of type I collagen and their combinations were compared with the level and duration of pain response to radionuclide treatment. RESULTS: Pain response was correlated only with pretreatment NuTaux/PINP, PICP/PINP and NTx/CTx ratios and posttreatment decrease in baseline NTx and PICP values (p = 0.0025-0.035). According to multivariate and ROC analyses, the best marker-derived predictors of better and longer duration of response to (186)Re-HEDP treatment were a posttreatment decrease in NTx of > or = 20% (RR = 3.44, p = 0.0005) and a pretreatment NTx/PINP ratio of > or = 1.2 (RR = 3.04, p = 0.036) CONCLUSION: NTx, a potent collagenous marker of bone resorption, along with the novel NTx/PINP ratio provide useful cut-off values for identifying a group of patients suffering from painful osseous metastases from hormone-refractory prostatic carcinoma who do not respond to palliative treatment with (186)Re-HEDP. This information could help avoid an inefficient and expensive radionuclide treatment. Also, in the cohort of patients who will eventually undergo such treatment, the medium-term posttreatment changes in NTx offer valuable predictive information regarding long-term palliative response.

Clinical and imaging correlations of bone turnover markers in prostate cancer patients with bone only metastases.

OBJECTIVES: To correlate serum levels of bone markers with pain levels and extent of skeletal disease (EOD), in patients suffering from prostate cancer with bone only metastases. METHODS: Thirty-six males with hormone-refractory prostate carcinoma, bone only metastases and no history of therapies, drugs, or diseases that affect bone metabolism were studied. Karnofsky performance status, pain scoring, EOD, osteocalcin (OC), prostate-specific antigen, bone alkaline phosphatase amino-terminal and carboxy-terminal propeptides and telopeptides of type I collagen were analysed. Twenty-four healthy controls of the same age were also established. RESULTS: With only the exception of OC, bone marker values of patients were significantly increased compared with the upper reference limits (P<0.0001 for bone alkaline phosphatase and amino-terminal telopeptide of type I collagen, 0.012 for amino-terminal propeptide of type I collagen, 0.0023 for carboxy-terminal propeptide of type I collagen, and 0.04 for carboxy-terminal telopeptide of type I collagen). All bone markers and prostate-specific antigen also showed significant paired correlations (P < or = 0.019) and linear increases with advancing EOD (P < or = 0.032). Finally, none of the measured markers correlated significantly with pain levels. CONCLUSION: Bone markers are remarkably elevated in the serum of prostate cancer patients with metastatic bone disease and correlate with EOD. Paired correlations also suggest an accelerated but proportional (coupled) bone metabolism.

Detection of human herpesvirus 8 in the skin of patients with pityriasis rosea.

Pityriasis rosea is an acute self-limiting dermatosis with clinical and epidemiological features that suggest viral involvement. The aim of this study was to investigate a possible association between pityriasis rosea and human herpesvirus 8 (HHV-8). Lesional skin tissue was obtained from 34 Kaposi's sarcoma-negative, immunocompetent patients with typical acute phase pityriasis rosea. Nested polymerase chain reaction with specific primer for HHV-8 DNA sequences was performed and all positive results were confirmed by sequencing. Seven out of 34 lesional skin specimens (20.5%) were found to be positive for the HHV-8 genome. All the positive samples were confirmed by DNA sequencing. We conclude that, in some cases, HHV-8 is implicated the pathogenesis of pityriasis rosea.

Early neurophysiological evolution of chronic inflammatory demyelinating polyneuropathy in a patient with Hashimoto's thyroiditis.

A patient with a known history of hypothyroidism due to Hashimoto's thyroiditis presented with a subacute, progressive sensorimotor deficit that affected the upper limbs predominantly. The electrophysiological findings progressively evolved from multifocal motor conduction block to multifocal demyelinating sensory and motor nerve involvement with conduction block, and finally to findings fulfilling the diagnostic criteria of chronic inflammatory demyelinating polyneuropathy (CIDP). The patient did not respond adequately to intravenous immunoglobulin, whereas oral prednisone led to fast and complete recovery. This report discusses the evolution of early findings of CIDP, as well as its coexistence with Hashimoto's thyroiditis.

Airway inflammation in obstructive sleep apnea: is leptin the missing link?

BACKGROUND: Local and systemic inflammation is implicated in the pathophysiology of Obstructive Sleep Apnea (OSA). Exhaled breath condensate (EBC) is a non-invasive sampling method for the lower airways. However, it is important to consider the potential effect of the systemic origin whereas systemic inflammation is significantly elevated. This prospective study was designed to investigate whether airway inflammation is significantly related to plasma leptin levels in OSA patients. Simultaneously, it was designed to investigate whether inflammatory variables predict parameters expressing disease severity and finally whether smoking habit affect the above measurements. PATIENTS & METHODS: About 45 OSA patients (mean AHI 40+/-25, 28 smokers) and 25 healthy controls (AHI<5, 15 smokers) were studied and underwent overnight diagnostic polysomnography. We measured pH, 8-isoprostane, TNF-alpha and IL-6 in EBC and leptin in plasma. Plausible associations between leptin and inflammatory parameters were analyzed after adjustment for proper variables. Similar associations between inflammatory variables and parameters of disease severity were also performed. RESULTS: An increased level of leptin and respective increase of inflammatory variables was found. No significant association was observed between parameters of EBC and plasma leptin levels. A part of the parameters of disease severity is significantly associated with pH and 8-isoprostane. Smoking did not seem to be a critical confounding factor for evaluation of the above measurements. CONCLUSIONS: Increased levels of leptin were not associated with the observed airway inflammation in OSA. The observed airway inflammation seemed to be independent of smoking habit with limited association with disease severity.

Isocapnic cold air challenge in patients with COPD: are there any predisposing factors?

Cold air hyperventilation is an indirect challenge (cold air challenge, CACh) with high specificity and low sensitivity in defining asthmatic subjects. A small proportion of chronic obstructive pulmonary disease (COPD) patients present with positive CACh. The aim of this prospective study was to investigate the presence of factors related to cold air challenge (CACh) in COPD patients. Factors examined were FEV(1), FEV(1)/FVC, reversibility after bronchodilation, eosinophils in induced sputum, bronchial hyperresponsiveness to methacholine and the spirometric response to tiotropium compared to placebo. We studied 92 consecutive COPD patients in order to retrieve 15 CACh positive + patients. Fifteen COPD patients with negative CACh [CACh(-)], randomly selected from the initial group, were added in order to retrieve a group of 30 patients. Spearman's correlation coefficient was used in order to evaluate possible significant correlations between CACh values and study parameters. Sixteen percent of our subjects presented CACh+. CACh values were repeatable with an intraclass correlation coefficient between the two measurements 0.980 (95% CI 0.940-0.993). The only significant correlation observed was between Delta FEV(1) after CACh [Delta(C)FEV(1)] and trough FEV(1) values post tiotropium inhalation (r(2) = 0.62, p < 0.0001). When we analyzed the response to tiotropium in the 2 separate groups we found that patients with CACh+ presented significantly lower values of trough FEV(1) compared to those with CACh(-). In conclusion, a small proportion of COPD patients present with bronchial hyperresponsiveness to CACh. The only parameter related to CACh + in our study was a smaller bronchodilating effect of tiotropium.

Body mass and fat-free mass indices in COPD: relation with variables expressing disease severity.

BACKGROUND: COPD primarily affects the lungs but also produces systemic consequences that are not reflected by the recent staging according to Global Initiative for Chronic Obstructive Lung Disease (GOLD) guidelines. Body mass index (BMI) and fat-free mass index (FFMI) represent different aspects of nutrition abnormalities in COPD. We investigated whether BMI and FFMI could be related to parameters expressing airflow obstruction and limitation, exercise capacity, airway inflammation, and quality of life, and whether they would reflect the GOLD staging of the disease. METHODS: One hundred patients with clinically stable COPD equally classified into the five stages of the disease were evaluated for BMI, FFMI (measured by bioelectrical impedance analysis), airway obstruction and hyperinflation (FEV(1), FEV(1)/FVC, inspiratory capacity), exercise capacity (6-min walk distance [6MWD], Borg scale before and after 6MWD]), chronic dyspnea using the Medical Research Council (MRC) scale, airway inflammation (sputum differential cell counts, leukotriene B(4) in supernatant), and quality of life (emotional part of the chronic respiratory disease questionnaire). RESULTS: 6MWD was significantly associated with both BMI and FFMI values, while FFMI additionally presented significant correlations with MRC scale, percentage of predicted FEV(1), and FEV(1)/FVC ratio. No association was observed between the two nutritional indexes. BMI was not statistically different among patients in the five stages of COPD, while FFMI reflected the staging of the disease, presenting the highest values in stage 0. CONCLUSIONS: Nutritional status is mainly related to exercise capacity. FFMI seems to be more accurate in expressing variables of disease severity, as well as the current staging compared to BMI.

Nonsurgical treatment of bilateral emphysematous pyelonephritis in a diabetic patient.

Bilateral emphysematous pyelonephritis is a rare life-threatening condition affecting almost exclusively patients with diabetes mellitus. Symptoms, which include fever, chills, abdominal and flank pain, nausea, vomiting, dysuria and pyuria, usually mimic those of classic pyelonephritis, and thus clinical suspicion for this urgent condition should be raised in every diabetic patient with similar presentation. Computed tomography (CT) remains the gold standard for the diagnosis demonstrating gas in the renal parenchyma, collecting system or perinephric tissue. Treatment, which should be aggressive, is classically surgical, and early nephrectomy is recommended. Percutaneous drainage associated with medical treatment might be an alternative. Successful exclusively medical treatment has been described but is infrequent and is reserved as an alternative for patients in whom surgical intervention is contraindicated. We report a case of bilateral emphysematous pyelonephritis in an 82-year-old female diabetic patient who presented with symptoms of typical pyelonephritis. Diagnosis was confirmed by CT, and Escherichia coli was identified as the causative factor. The patient was successfully treated medically with intravenous administration of cefepime and amikacin for 14 days and recovered fully. The therapeutical options for this severe but rare condition are discussed.

Decreasing nasal mucus Ca++ improves hyposmia.

It is well documented that cytoplasmic Ca++ regulates sensitivity to cyclic adenosine monophosphate (cAMP). There is also evidence that Ca++ in the mucus may also modulate sensitivity to cAMP in vivo. Assuming that mucosal Ca++ could significantly change the excitability of the receptor neurons, we examined the alterations in the olfactory sensitivity by creating small changes in mucosal Ca++. Thirty one patients complaining of olfactory loss were examined and their olfactory acuity was measured before and after the administration of a sodium citrate buffer solution in the nasal cleft. Thirty patients (96.8%) improved their scores in less than an hour period of time. Furthermore, 23 of them (74.2%) realized an improvement in their own sense of smell.