Legionnaires' disease.

Described here is a unique case of Legionnaires' disease in a previously healthy 46 year old man in whom disseminated disease was demonstrated in the kidneys, bone marrow, spleen and multiple peripheral lymph nodes at autopsy. The pathologic distribution of the lesions suggests that dissemination occurred by both hematogenous and lymphatic pathways. Pancytopenia associated with bone marrow destruction and fibrosis suggests that substances toxic to hematopoietic cells were present. It is likely that many of the unusual systemic manifestations of this disease are related to dissemination of the bacterium. The findings presented extend the spectrum of the clinical and pathologic manifestations of Legionnaires' disease from a mild and self-limited illness to a severe and fatal disseminated form of the disease.

Inequality, poverty and development.

PIP: Dicussion explores the nature of the relationship between the distribution of income and the process of development on the basis of cross country data on income inequality. The results presented are based on a sample of 60 countries, including 40 developing countries, 14 developed countries, and 6 socialist countries. The approach adopted is essentially exploratory. Multivariate regression analysis was used to estimate cross country relationships between the income shares of different percentile groups and selected variables reflecting aspects of the development process which are likely to influence income inequality. The estimated equations are then used as a basis for broad generalizations about the relationship between income distribution and development. There was strong support for the proposition that relative inequaltiy increases substantially in the early stages of development, with a reversal of this tendency in the later stages. The propositions held whether the sample was restricted to developing countries or expanded to include developed and socialist countries. The process was most prolonged for the poorest group. There were a number of processes occurring "pari passu" with development which were correlated with income inequality and which can plausibly be interpreted as causal. These were intersectoral shifts in the structure of production, expansion in education attainment and skill level of the labor force; and reduction in the growth of population. The operation of these processes appeared to explain some of the improvement in income distribution observed in the later stages of development, but they did not serve to explain the marked deterioration observed in the earlier stages. The cross section results failed to support the stronger hypothesis that the deterioration in relative inequality reflected a prolonged absolute impoverishment of large sections of the population in the course of development. The cross country pattern showed average absolute incomes of the lower percentile groups rising as per capita gross national product rises, although slower than for upper income groups. The cross section results failed to support the view that a faster rate of growth is systematically associated with higher inequality than can be expected given the state of development realized. An appendix identifies data sources and problems.^ieng

Medical management of pneumatosis intestinalis in patients undergoing allogeneic blood and marrow transplantation.

Pneumatosis intestinalis (PI) occurs when gastrointestinal (GI) wall disruption, increased wall permeability or necrosis leads to wall infiltration by gas. It is associated with a spectrum of causal factors, including GI disease in allogeneic blood and marrow transplant patients. Traditionally, PI has been managed surgically with high morbidity and mortality. We describe our experience managing allogeneic blood and marrow transplant patients with PI. From January 1998 to May 2008, 320 patients underwent allogeneic blood and marrow transplant of whom 10 were identified with PI. PI diagnosis was established by computed tomography scan (n=7), plain film (n=2) or colonoscopy (n=1). A total of 9 of 10 patients had ongoing GI GvHD or received recent treatment for GI GvHD. Before April 2002, two patients underwent subtotal colectomy with ileostomy (n=1) and sigmoid colectomy with colostomy (n=1). One patient was managed with bowel rest and total parental nutrition (TPN) only. These three patients died 0.4, 1.1 and 3.9 years after PI diagnosis owing to GI GvHD (n=2) and surgical complications (n=1). Seven patients, diagnosed after September 2006, were treated with GI rest, TPN and antibiotics. PI treated with GI rest, TPN and antibiotics will resolve without surgical intervention. AlloBMT-associated PI is often a non-critical finding that does not represent true GI tract ischemia and/or GI tract perforation.