Occult dental infection as a cause of fever of obscure origin.

Three patients with prolonged unexplained fevers were ultimately found to have deep-seated dental infection. After initial examination failed to elicit symptoms or signs of dental infection, and extensive in-hospital evaluation was nonproductive, dental consultation with roentgenograms provided the diagnosis. All three patients underwent dental extractions with periapical or peridontal debridement; following a brief postoperative febrile period, all three responded with defervescence, without subsequent recurrence of fever. These cases emphasize the importance of periapical and peridontal infection as causes of fever of obscure origin. The pathogenesis, characteristics and bacteriology of periapical abscess are discussed.     

Clinical recognition of giant left ventricular aneurysm

The noninvasive diagnosis of left ventricular aneurysm has markedly improved with gated blood pool scintigraphy. However, in patients with giant anterior ventricular aneurysms, the gated blood pool scintigram performed in two standard views (anterior and 40 degree left anterior oblique) may incorrectly suggest ischemic cardiomyopathy. We retrospectively identified five patients who underwent resection of a ventricular aneurysm over a $\text{2}\text{1}\text{2}$ year period and who had preoperative scintigraphic studies that appeared to show severe diffuse left ventricular dysfunction. Contrast ventriculography demonstrated preserved wall motion in septal, inferior and lateral segments not seen by gated blood pool scintigraphy and showed extraordinarily large anterior aneurysms. M-mode or two-dimensional echocardiograms showed intact posterior wall function in all patients, suggesting severe regional myocardial disease rather than global dysfunction. Two-dimensional echocardiography showed additional segments with preserved function as well as discrete aneurysms in all patients. We conclude that gated blood pool scintigraphy, when performed in two standard views, may fail to correctly diagnose some patients with very large anterior wall aneurysms. M-mode echocardiography, two-dimensional echocardiography and additional scintigraphic views that visualize the posterior portions of the left ventricle improve noninvasive diagnosis of patients with resectable giant left ventricular aneurysms.     

Granulocytopenia in hospitalized patients: I. Prognostic factors and etiology of fever

The clinical course of 126 hospitalized patients during 192 episodes of granulocytopenia and fever was studied. Fever was a regular accompaniment of granulocytopenia, occurring in 94 per cent of granulocytopenic episodes. The mean duration of granulocytopenia (less than 1,000/mm3) was 18 days, with fever (temperature greater than 38 degrees C) being present during 44 per cent of those days. Fever was present during 69 per cent of days with a granulocyte count less than 10/mm3. A presumed infection was present in 86 of 128 febrile granulocytopenic episodes in adults and in 19 of 64 febrile granulocytopenic episodes in children. A fungal infection was found in 11 patients; a viral infection in 23 patients. Bacteremia occurred during 44 granulocytopenic episodes with 16.8 bacteremias/1,000 days of granulocytopenia in adults and 12.7 bacteremias/1,000 days in children. The mortality was 33 per cent per granulocytopenic episode in adults and only 8 per cent per episode in children.     

Symptomatic normovolemic essential hypernatremia. A clinical and physiologic study

A 23 year old man presenting with episodic muscle paralysis and persistent normovolemic hypernatremia and hyperosmolality was investigated. Metabolic studies at the time of presentation and during a 10 hour fast, and the responses to acute and chronic water loading, alcohol, vasopressin and nicotine infusion, sodium restriction and intravenous sodium loading were all normal, with the exception of the acute water load. These results suggested abnormal hypothalamic function leading to an altered regulation of the central osmoreceptors controlling thirst and sodium metabolism; however, no central nervous system lesion was demonstrable. Despite normal levels of plasma [potassium], total exchangeable body potassium was reduced. It is proposed that the muscle paralysis was secondary to both the hypernatremia and the reduced total body potassium status. Progressive symptomatic improvement with lowering of plasma sodium and osmolality occurred following 24 months on a low sodium-high potassium-high fluid regimen although total body potassium status has remained low.     

Chronic membranoproliferative glomerulonephritis: A patient with recurrent episodes simulating rheumatic fever and acute nephritis

A most unusual case of chronic membranoproliferative glomerulonephritis with nodule formation is reported in an elderly man in whom it was possible to document many episodes of acute oliguric and hemorrhagic glomerulonephritis and a syndrome resembling acute rheumatic fever. Severe renal failure necessitating peritoneal dialysis occurred on three occasions. Renal function returned to near preexacerbation levels in each episode. Although there was strong clinical evidence for streptococcal hypersensitivity, convincing laboratory documentation was lacking. The histologic and immunopathologic findings changed comparatively little during the several exacerbations. Impairment in fibrinolytic and coagulation activities by circulating macromolecular complexes is postulated for the induction and perpetuation of the glomerular injury.     

Erythropoietin-producing renal cyst and polycythemia vera. Clarification of their relationship

Described here is a patient with the splenomegaly, pancytosis and panhyperplastic marrow of polycythemia vera who was found to have bilateral renal cysts. Erythropoietin levels in the serum and in fluid from the cyst on the left kidney were elevated. After puncture, fluid aspiration and injection of a sclerosing solution into the cyst on the left kidney, the serum erythropoietin level became undetectable. Subsequent puncture of the cyst on the right kidney showed no erythropoietin activity in the cyst fluid. However, the patient's signs of polycythemia vera persisted. Specimens of the patient's marrow grown in vitro showed a lack of response to erythropoietin stimulation, characteristic of polycythemia vera. This case, with defined diagnostic criteria and erythropoietin levels before and after therapy, suggests that the association of renal cysts and pancytosis is coincidental, as opposed to the documented endocrinologic relationship between secondary erythrocytosis and erythropoietin-producing renal lesions. In eight cases of concomitant pancytosis and renal cysts, described in the literature, the question of a causal versus a coincidental relationship was raised but unanswered.     

Angioimmunoblastic lymphadenopathy with dysproteinemia. A pathogenetic link between lymphoid proliferation and malignant lymphoma.

Two patients with angioimmunoblastic lymphadenopathy with dysproteinemia (AILD) were studied. Both patients had marked increases in all three major immunoglobulin classes, and both lacked suppressor cell activity in vitro. These findings are consistent with the theory that AILD is a defectively regulated immune response to an unidentified antigen(s) and could provide clues to the pathogenesis of other lymphoproliferative disorders as well.     

Immunodeficiency, malabsorption and secretory diarrhea. A new syndrome.

Described here is a patient with severe watery diarrhea associated with common variable immunodeficiency. Malabsorption for fat, bile acids, vitamin B12 and xylose was demonstrated, but the patient failed to respond to all the usual therapeutic maneuvers. The diarrhea responded only to high dose steroid therapy. Intestinal perfusion studies showed a hitherto undescribed, presumably acquired, glucose-stimulated water, sodium and chloride secretion in the jejunum and ileum, whereas normal fluid and electrolyte transport occurred from bicarbonate and mannitol solutions. Glucose absorption itself was normal and no hormonal, morphologic or biochemical defect was demonstrated to account for the phenomenon. The patient was also interesting when compared with other patients with common variable immunodeficiency in having normal plasma cells in the intestinal mucosa and an extensive family involvement.     

Salmonella heidelberg enteritis and bacteremia. An epidemic on two pediatric wards.

Symptomatic infection with Salmonella heidelberg developed in 55 children after their admission to the pediatric wards of two adjacent hospiatls in San Juan, Puerto Rico. Many of these children had been hospitalized for the treatment of diarrhea of unidentified etiology. In 25 of these patients, Salmonella bacteremia was documented. Five had clinically unsuspected and untreated bacteremia with no evidence of complications during the follow-up period of four and a half months. The remaining 30 had "standard" symptomatic infection due to S. heidelberg. Eight children died; four of these proved to be bacteremic. The index patient, who also introduced the infection into one of the hospitals, was identified. Person to person spread perpetuated the outbreak within and between the two hospitals for nearly four months. Although neonates with salmonellosis had a higher rate of bacteremia than other children, no other specific predisposing factors for Salmonella bacteremia were identified. Laboratory studies of the epidemic strain revealed neither invasive nor enterotoxic properties of the organisms, nor enhanced virulence in laboratory mice. Cohort nursing and isolation of patients with positive cultures halted the epidemic. Nontyphoid Salmonella bacteremia, sometimes clinically unsuspected and self-limited, should be recognized as a frequent accompaniment of Salmonella enteritis in young hospitalized children.     

Current therapy of hypertension. A pharmacologic approach.

Adequate treatment of hypertension requires that the physician understand the pharmacologic actions of antihypertensive agents. Although no drug is without adverse reactions, it should be possible to choose an agent or combination of agents which can effectively lower blood pressure and be tolerated by the patient. The indications, proposed mechanisms of actions and adverse effects of the following antihypertensive drugs are discussed: thiazide diuretics, spironolactone, triamterene, trimethaphan, Rauwolfia alkaloids. guanethidine, bethanidine, methyldopa, clonidine, pargyline, propranolol, hydrazaline, minoxidil, guancydine, diazoxide and sodium nitroprusside.     

Complications and consequences of endotracheal intubation and tracheotomy: A prospective study of 150 critically ill adult patients

A prospective study of the complications and consequences of translaryngeal endotracheal intubation and tracheotomy was conducted on 150 critically ill adult patients. Adverse consequences occurred in 62 percent of all endotracheal intubations and in 66 percent of all tracheotomies during placement and use of the artificial airways. The most frequent problems during endotracheal intubation were excessive cuff pressure requirements (19 percent), self-extubation (13 percent) and inability to seal the airway (11 percent). Patient discomfort and difficulty in suctioning tracheobronchial secretions were very uncommon. Problems with tracheotomy included stomal infection (36 percent), stomal hemorrhage (36 percent), excessive cuff pressure requirements (23 percent) and subcutaneous emphysema or pneumomediastinum (13 percent). Complications of tracheotomy were judged to be more severe than those of endotracheal intubation. Follow-up studies of survivors revealed a high prevalence of tracheal stenosis after tracheotomy (65 percent) and significantly less after endotracheal intubation (19 percent) (p < 0.01). Thirty-nine of 41 (95 percent) patients with endotracheal intubation and 20 of 22 (91 percent) patients with tracheotomy had laryngotracheal injury at autopsy. Ulcers on the posterior aspect of the true vocal cords were found at autopsy in 51 percent of the patients who died after endotracheal intubation. There was no significant relationship between the duration of endotracheal intubation or tracheotomy and the over-all amount of laryngotracheal injury at autopsy, although patients with prolonged endotracheal intubation followed by tracheotomy had more laryngeal injury at autopsy (P = 0.06) and more frequent tracheal stenosis (P = 0.05) than patients with short-term endotracheal intubation followed by tracheotomy. Adverse effects of both endotracheal intubation and tracheotomy are common. The value of tracheotomy when an artificial airway is required for periods as long as three weeks is not supported by data obtained in this study.     

Total occlusion of the left main coronary artery. A clinical, hemodynamic and angiographic profile

Although left main coronary artery stenosis has been extensively revicwed, total occlusion of the left main coronary artery has received scant attention. Six patients were diagnosed at cardiac catheterization as having total occlusion of the left main coronary artery over a period of seven years at two institutions. They ranged in age from 32 to 72 years, and all had symptoms ranging from NYHA Class 1-IV at initial presentation. One patient died three days after coronary artery bypass graft surgery. Of the remaining five, two treated medically are alive four and 40 months after catheterization, and three treated with coronary artery bypass graft surgery are alive three, 66 and 68 months after catheterization. Electrocardiogram showed prior myocardial infarction in three patients, stress tests were positive in three of four patients, and hyperlipidemia was present in the five tested. In the three patients without prior myocardial infarction, left ventricular function was preserved (ejection fractions = 0.52, 0.55 and 0.64; left ventricular end-diastolic pressures = 6, 9 and 14 mm Hg). Injection of the right coronary artery in this group revealed extensive collaterals filling the left coronary artery. The three patients with prior myocardial infarction had impaired left ventricular function (ejection fractions = 0.18, 0.30 and 0.33; left ventricular end diastolic pressures = 26, 35 and 35 mm Hg) and sparse intercoronary collaterals. Patients with total occlusion of the left main coronary artery have a varying clinical presentation and may have prolonged survival. In patients with good collaterals, left ventricular function may be preserved.     

A prospective controlled investigation of prophylactic trimethoprim/sulfamethoxazole in hospitalized granulocytopenic patients.

Oral trimethoprim/sulfamethoxazole (TMP/SMZ) therapy was investigated in the prophylaxis of infections in granulocytopenia. Hospitalized granulocytopenic patients were allocated at random to receive TMP/SMZ (group 1) or to a control group (group 2). The percentage of febrile granulocytopenic days was significantly reduced in group 1, 19 per cent compared to 39 per cent in group 2 (P less than 0.01). In group 1, there were no bacteremias in 59 episodes of granulocytopenia (909 days). In group 2, there were nine bacteremias in 52 episodes of granulocytopenia (796 days)(P = 0.001). Disseminated candidiasis developed in two patients in each group. Candida occurred in similar numbers in surveillance cultures in both groups; Staphylococcus aureus and Pseudomonas aeruginosa were slightly decreased, and Enterobacteriaceae resistant to TMP slightly increased in group 1. This study suggest that oral prophylactic TMP/SMZ therapy is an effective, well tolerated, easily administered alternative to "gut sterilization" with nonabsorbable antibiotics.     

Gallium scanning for the detection of abdominal abscesses

The use of gallium scanning for the diagnosis of abdominal abscesses was studied in 59 cases in which the diagnosis was verified by laparotomy or autopsy. In 23 of the cases the patients were subsequently found to have abdominal abscesses and 11 patients had abdominal malignancies. Excluding the latter group, the scan was specific for abscess in 86 per cent of the cases and sensitive for abscess in 67 per cent. Recent abdominal incisions, concurrent intestinal, hepatic, biliary and pancreatic inflammatory conditions, without abscess, seldom caused gallium accumulation. False-negative scans (18 per cent) occurred more frequently than false-positive scans (8 per cent) and were seen in patients with large (often palpable) masses of short evolution and with secondarily infected lesions such as hematomas and pseudocysts. the gallium scan was of little help in the search for abdominal lesions in patients with obscure febrile illnesses without abdominal symptoms or signs.     

Emphysematous pyelonephritis. A report of two cases

Emphysematous pyelonephritis is a suppurative infection of the renal parenchyma characterized by the production of gas by bacteria through fermentation. Although seemingly rare, this condition occurred in two diabetic patients on general medical wards over a two year period. Diagnosis, in an appropriate clinical setting, is confirmed roetgenologically. Escherichia coli is the most common etiologic organism. Despite appropriate medical and surgical intervention, this severe form of renal parenchymal infection carries a high mortality.     

Left atrial transport function in myocardial infarction. Importance of its booster pump function.

After myocardial infarction (MI), left ventricular (LV) end-diastolic pressure (EDP) is higher than mean pulmonary artery wedge pressure because of powerful atrial contraction. To evaluate the significane of atrial contraction to left ventricular function we studied 10 control (C) patients without cardiac disease and 17 patients from three to six weeks after acute myocardial infarction. Cardiac catheterization with simultaneous left ventricular diastolic pressure (DP) and left ventricular cineangiograms were obtained. Left ventricular volumes and pressure were (mean +/- SD): (SEE ARTICLE). Although left ventricular stroke volume was lower in the patients with myocardial infarction than in the control subjects (46 versus 56 ml/m2), atrial contraction contributed more to left ventricular filling during diastole (which is the same as left ventricular stroke volume) in the patients with myocardial infarction than in the controls (16 versus 10 ml/m2). The average atrial contribution to left ventricular end-diastolic volume was 11.9 per cent (C), 15.4 per cent (MI); to left ventricular end-diastolic pressure 20 per cent (C), 38.7 per cent (MI); and to left ventricular stroke volume 21.7 per cent (C), 35.1 per cent (MI). Atrial contribution to left ventricular stroke volume was 56 per cent in patients with a cardiac index less than or equal to 2.0 liters/min/m2 and 31 per cent in those with a cardiac index greater than 2 liters/min/m2 (p less than 0.01). Atrial contraction contributed 35 per cent to left ventricular stroke volume in patients with normal end-diastolic volume and in those with increased end-diastolic volume and 10 per cent to end-diastolic volume in patients with increased end-diastolic volume (p less than 0.001). In patients with myocardial infarction, atrial contraction made a large contribution to left ventricular filling and stroke volume irrespective of the type of left ventricular functional derangement that was present. The "booster pump" function of the atrium cannot be ignored in assessing left ventricular performance.     

Cell wall-deficient bacterial variant cultural surveillance. A useful laboratory aid.

A cell wall-deficient variant of Corynebacterium species was isolated from the blood of a patient with a chronic febrille illness of unkown etiology. He was given antimicrobial therapy, to which both variant and reverted bacterial forms of this organism were sensitive, and he recovered. Cultural surveillance for cell wall-deficient organisms was not only helpful in confirming the presence of infection in our patient but also in following his clinical course once antimicrobial therapy had been instituted.     

The reflex sympathetic dystrophy syndrome. II. Roentgenographic and scintigraphic evidence of bilaterality and of periarticular accentuation.

Patchy osteoporosis is the primary roentgenologic manifestation of the reflex sympathetic dystrophy syndrome (RSDS). As recent clinical and histologic data suggested articular changes in RSDS, fine-detail roentgenograms were obtained in eight consecutive patients. Juxta-articular and soft-tissue swelling, osteoporosis and erosions of the subchondral bone were found. 99mTcO4 and 99mTc-EHDP scintigraphy showed localization of nuclide predominantly in the juxta-articular tissues. Serial roentgenographic, scintigraphic and quantitative bone densitometric measurements showed changes that reflected the clinical course of the disease.     

Association of a chromosomal abnormality with lymphocytes having both T and B markers in a patient with lymphoproliferative disease.

The lymphocytes of a patient with leukemic lymphosarcoma were found to have an unusual surface phenotype in that they bound both sheep erythrocytes (a T cell marker) and complement-coated erythrocytes (a B cell marker) but lacked other B cell surface characteristics. Marker chromosomes were present in these cells, but not in other, phenotypically normal cells from the same patient. This case may provide a clue to the chromosomal origin of some lymphocyte surface markers in man.