The adverse impact of cytomegalovirus infection on clinical outcome in cyclosporine-prednisone treated renal allograft recipients

Cytomegalovirus (CMV) infection was diagnosed in 28% (n = 144) of 516 renal allograft recipients treated with cyclosporine-prednisone (CsA-Pred) immunosuppressive therapy. The majority of infections produced either asymptomatic (n = 37) or mild-to-moderate (n = 75) clinical disease, while 10% were lethal (n = 14). Transplantation from a seropositive donor to a seronegative recipient was associated with an increased incidence of (CMV) infection but did not predispose to more severe clinical disease. Similarly, donor source (cadaver [CAD] vs. living-related donor [LRD]), age greater than or equal to 45 years, and antecedent pulse steroid therapy for the treatment of acute rejection were not correlated with clinically more severe disease. An increase in serum creatinine to greater than or equal to 25% of preinfection nadir values occurred in association with CMV infection in 106 patients, returning to nadir values or below in 74.5% of these individuals. CMV infection did not impact on actual patient survival among recipients of LRD or CAD allografts or on actual 1-year HLA-haploidentical or HLA-identical LRD graft survival. In contrast, actual 1-year cadaveric graft survival was significantly lower among CMV-infected (n = 95) vs. uninfected (n = 198) patients (75.8% vs. 87.8%, P = .01). In association with the finding of reduced actual 1-year CAD graft survival, CMV-infected patients were found to be more predisposed to develop acute rejection episodes. Of the CMV-infected CAD graft recipients, 48.4% developed greater than or equal to 1 acute rejection episode during the first year following transplantation vs. 25.3% of their uninfected counterparts (P less than .001). The impact of CMV infection in CsA-Pred treated renal transplant recipients does not differ substantially from that reported historically in association with prednisone-azathioprine immunosuppressive therapy.     

Treatment of Raynaud's phenomenon with triiodothyronine corrects co-existent autonomic dysfunction: preliminary findings.

Cardiovascular autonomic function was assessed in 9 subjects with Raynaud''s phenomenon. The underlying diseases were systemic lupus erythematosus (n = 5), systemic sclerosis (n = 3) and rheumatoid arthritis (n = 1). Five standard non-invasive tests, 3 of heart rate and 2 of blood pressure, were employed. Compared with age and sex matched controls (n = 25), the number of values abnormal was 24 of 45 (53%) overall and between one and 4 (median, 2) individually. Significant differences were present for 3 tests, two of heart rate and one of blood pressure. The subjects were given triiodothyronine, 60 to 80 micrograms per day, for vasospastic attacks. Autonomic function was reassessed between weeks 4 and 9 (9 subjects) and between weeks 12 and 18 (8 subjects) after introduction of triiodothyronine. Test results showed a considerable improvement. At the second reassessment, the number of values abnormal was now 5 of 40 (12.5%) overall and nil (n = 4) or one (n = 4) individually. Significant differences remained for one heart rate test only. Adverse side effects to triiodothyronine occurred in a single subject and were readily controlled. Evidence of somatic neuropathy was present electrophysiologically in all 9 subjects and clinically in 8. Triiodothyronine may have corrected autonomic dysfunction by increasing blood flow to ischaemic peripheral nerves or by acting on the autonomic system more directly. Further study of triiodothyronine in autonomic insufficiency appears merited.     

Dose-dependent kinetics of the enantiomers of MK-571, an LTD4-receptor antagonist

Summary The disposition of the enantiomers of MK-571 (MK-0679 and L-668,018) following single i. v. doses of MK-571 (L-660,711) was studied in a three way cross-over study in 12 healthy male volunteers. Each volunteer received 75 mg, 300 mg and 600 mg i. v. doses of MK-571 at weekly intervals.The disposition of both enantiomers appeared dose-dependent, since the AUC increased disproportionately faster than the dose. The dose dependency was much more pronounced for L-668,018: its AUC increased 6-fold from the 75 to the 300 mg dose, 16-fold from 75 to 600 mg and 2.7 fold from 300 to 600 mg. For MK-0679, the corresponding increases in AUC were 4.8-, ll-, and 2.3 fold. Regardless of dose, the elimination of L-668,018 was more rapid than that of MK-0679.The disposition of MK-0679 needs to be investigated independently to detect any potential influence of L-668,018 on its disposition.     

Coccidioidal peritonitis associated with continuous ambulatory peritoneal dialysis

We report the first three cases of peritonitis due to the fungus Coccidioides immitis occurring during continuous ambulatory peritoneal dialysis (CAPD). At the time of diagnosis, none of the patients had evidence of active infection outside of the peritoneal cavity. Clues suggesting the diagnosis including a previous history of pulmonary coccidioidomycosis, an excess number of eosinophils in the peritoneal fluid, and failure to respond to therapy directed against bacteria. C immitis in peritoneal fluid was more readily isolated on specific fungal culture media than on routine bacterial culture media. In no instances did potassium hydroxide (KOH) preparations of the fluid reveal fungi. Coccidioidal peritonitis during CAPD appears to be a localized form of extrapulmonary coccidioidomycosis that has a relatively benign course once the peritoneal catheter is removed.     

Fractures of the atlas: classification, treatment and morbidity

Fractures of the atlas vertebra are generally considered to be innocuous injuries. A review of 35 patients with C1 fractures treated in the Acute Spinal Cord Injury Unit of Shaughnessy Hospital indicated that long-term morbidity is not as low as was previously thought. Thirteen of 23 patients (56%) followed up a minimum of 1 year post-trauma had significant symptoms of scalp dysesthesia, neck pain, and/or neck stiffness. A classification is presented, and the results of treatment modalities used are reviewed. Based on the findings, the simplest orthosis consistent with appropriate treatment of any of the often associated other spine fractures is recommended. Surgery is reserved for late instability or pain.     

Cerebral involvement in children with acute and relapsing inflammatory polyneuropathy

We present two children with seizures and other signs of cerebral involvement at the outset of acute inflammatory demyelinating polyneuropathy, consistent with a diagnosis of encephalomyeloradiculoneuropathy. One child had a recurrence associated with mild central dysfunction and improved during therapy with corticosteroids. Both children recovered completely. Both acute and relapsing inflammatory demyelinating neuropathy may be accompanied by cerebral dysfunction, expanding the clinical spectrum of encephalomyeloradiculoneuropathy.