Renal infarction due to renal artery dysplasia with dissection: Report of a case in a normotensive patient

A previously healthy 44-year-old man with well-documented normotension had a sudden onset of left flank pain and delayed onset of constitutional symptoms, hematuria, and elevations of lactic dehydrogenase, serum glutamic oxaloacetic transaminase, serum glutamic pyruvic transaminase, and creatinine levels. Angiography revealed unilateral renal artery fibromuscular dysplasia with dissection and infarction. In the year since, he has remained well and normotensive without therapy. The literature is reviewed.     

Adverse effects of liquid protein fast on the handling of magnesium,calcium and phosphorus

We have studied the effect of a vitamin- and potassium-supplemented liquid protein fast on mineral metabolism of six obese subjects (five women, 1 man) for 40 days. Each patient was admitted to a metabolic ward and was given daily 300 Kcal, 75 mg of calcium, 406 mg of phosphorus, 7 mg of magnesium, 33 meq of potassium, and 11.5 g of nitrogen. Urinary calcium, phosphorus and magnesium levels were greatest during the first week, but decreased as the fast continued to 21, 31 and 300 percent, respectively, above intake. Cumulative urinary losses of calcium, phosphorus and magnesium were 58, 75 and 500 percent greater, respectively, than the cumulative intake. Fecal losses for calcium, phosphorus and magnesium were less than urinary losses throughout the study. Cumulative fecal losses of magnesium were more than 30 percent greater than dietary intake. Mean daily balances were ?104 mg (calcium), ?48 mg (magnesium) and ?363 mg (phosphorus). Serum phosphorus and magnesium levels did not change. However, serum calcium levels decreased (?0.5 mg/dl, p < 0.05). Serum bicarbonate levels decreased 20 percent during the first 8 days of the fast, at which time urinary ammonium was maximal, but later returned to control values despite sustained increases in serum and urinary acids throughout the fast. Ammonium excretion was 260 to 300 percent above control values. Urinary titratable acid excretion was greatest early in the fast but subsequently decreased as the excretion of phosphorus declined. Titratable acid accounted for less of the excreted acid (7 to 21 percent) than did ammonia (70 to 90 percent). It is concluded that a liquid protein fast results in negative mineral balance that is not reflected by serum values and is due primarily to renal losses. The losses of magnesium were proportionally greater than those of calcium and phosphorus. These studies indicate that a liquid protein fast results in depletion of the intracellular and/or skeletal stores of these minerals.     

Effects of factors predisposing to atherosclerosis on formation of coronary collateral vessels

Two hundred eighteen consecutive patients undergoing selective coronary angiography were studied to determine the effects of underlying predisposing coronary risk factors on the formation of intercoronary collateral anastomoses. The presence or absence of hyperlipoproteinemia, diabetes mellitus, glucose intolerance, hypertension or obesity did not influence the formation of these intercoronary collateral channels. Our findings suggest that there are presently no measurable clinical factors that permit prediction of the presence of coronary collateral channels in an individual patient. Factors predisposing to atherosclerosis have a similar distribution in patients with and without such vessels.     

Thoracic skeletal abnormalities in idiopathic mitral valve prolapse.

Idiopathic prolapse of the mitral valve is a common disorder, but many cases are clinically subtle. Thoracic skeletal abnormalities, reported recently to accompany the syndrome, may serve as an easily identifiable clinical indicator. The prevalence of these abnormalities was defined in 24 patients with proved prolapse of the mitral valve. The valvular syndrome was defined clinically, by echocardiography and, in seven cases, by left ventricular angiography. The skeletal deformities were defined clinically and radiographically. Pectus excavatum was present in 62 percent of the patients, "straight back" in 17 percent and severe scoliosis in 8 percent. Eighteen of the 24 patients (75 percent) had a definite thoracic skeletal deformity. The association of idiopathic prolapse of the mitral valve with these skeletal deformities may represent a forme fruste of Marfan's syndrome. Patients with "straight back" and pectus excavatum should be examined clinically and perhaps by echocardiography to exclude idiopathic prolapse of the mitral valve; when murmurs are present, a diagnosis of "pseudoheart disease" should not be made before mitral valve prolapse has been excluded.     

Renal cortical and hepatic phosphoenolpyruvate carboxylase in the diabetic rat: effect of acid-base status

Phosphoenolpyruvate (PEP) carboxylase activity was determined in renal cortex and liver from diabetic rats given NaCl (acidotic) or NaHCO₃ (nonacidotic) and in normal animals given ammonium chloride or NaHCO₃. When compared with control animals, diabetic acidosis increased PEP carboxylase activity in both liver and renal cortex. Sodium bicarbonate administration to diabetic animals returned renal cortical enzyme activity to control levels, but failed to influence enzyme activity in liver. The increase in renal cortical PEP carboxylase activity following induction of acidosis with ammonium chloride in normal animals or in insulin-treated diabetic animals was similar, for any given reduction in plasma carbon dioxide, to that found during spontaneous diabetic acidosis. It is concluded that the increase in hepatic PEP carboxylase present during diabetes is secondary to the defect in carbohydrate metabolism and independent of the changes in acid-base status. In renal cortex, on the other hand, the increase in PEP carboxylase during diabetes is secondary to the associated acidosis and independent of the defect in carbohydrate metabolism.     

Renal involvement in Refsum's disease

Renal hemodynamic and tubular functions were measured in a patient with Refsum's disease before and after 12 weeks of twice-weekly plasmaphereses. Percutaneous renal biopsy was performed before initiation of plasmapheresis. These studies were performed to (1) define the nature of the renal lesions and the effects of phytanic acid accumulation on renal functions, and (2) assess the effects of lowering the plasma phytanic acid level on renal functions. The patient, a 39 year old woman, had lipiduria, glycosuria, cylindruria, minimal proteinuria and mild azotemia initially. Renal lesions consist of extensive vacuolization and mitochondrial changes of the tubular epithelial cells, vacuolization of the visceral epithelial cells of the glomeruli, and slight to moderate mesangial sclerosis. The impaired renal hemodynamic function and various tubular functions improved following plasmaphereses associated with reduction of plasma phytanic acid. Over-all clinical improvement was also evident.     

Spontaneous remission of the nephrotic syndrome in diabetic nephropathy

A 28 year old woman, with diabetes since age 18, had the nephrotic syndrome, hypertension and renal insufficiency. The initial renal biopsy specimen revealed diffuse glomerulosclerosis with early nodular changes. After an initial decline in renal function, her creatinine clearance progressively improved and has remained normal. Within 2 years she had a spontaneous remission of the nephrotic syndrome despite the presence of more pronounced nodular glomerular lesions. Although the renal hemodynamic functions were normal, certain tubular functions were impaired. Since we found no etiology for the nephrotic syndrome other than diabetic glomerulopathy, the complete remission of the nephrotic syndrome and improvement in renal function were very unusual events.     

Gram-negative bacillary endocarditis. Interpretation of the serum bactericial test.

Although the serum bactericidal test is commonly used in the management of infective endocarditis, little has been written about its validity or limitations. We report three cases of gram-negative bacillary endocarditis (Pseudomonas aeruginosa, Vibrio fetus and Serratia marcescens) encountered in 1 year at a Veterans Administration hospital. Serum bactericidal titers were considered necessary to identify inadequate antibiotic regimens or to avoid unnecessary drug toxicity. The limitations of the test, particularly those pertaining to gram-negative infections, are reviewed. Misleading results during treatment with aminoglycoside antibiotics could be due to the tendency of serum to become alkaline on standing. A detailed study of the interaction of the complement-dependent bactericidal system of serum with eight antibiotics is presented. In the context of the serum bactericidal test, the interaction was additive or synergistic in 15 of 16 determinations, indicating the need to include a control study of serum sensitivity of the infecting microorganism in each case.     

Persistent neutrophil dysfunction in an adult. Combined defect in chemotaxis, phagocytosis and intracellular killing

Impaired phagocytosis and killing of bacteria by neutrophils were demonstrated repeatedly in a 65 year old man. He had staphylococcal pyarthrosis and osteomyelitis. Phagocytosis and intracellular killing of Staphylococcus aureus by neutrophils of the patient were impaired, but no significant defect was noted when Candida was used as the test organism. Production of ¹⁴CO₂ from glucose-1-¹⁴C, glucose-6-phosphate dehydrogenase levels, nitroblue tetrazolium reduction test and myeloperoxidase levels were all normal in his neutrophils. The monocyte bactericidal capacity for Staph. aureus was normal. Despite normal migration demonstrated by the skin window technic and by the presence of numerous neutrophils in the joint aspirate, studies of neutrophil chemotaxis revealed an impaired response to chemotaxin, and an inhibitor of chemotaxis of normal neutrophils was also found in his serum. However, his serum generated chemotaxin normally. This neutrophil dysfunction appears to differ from that found in chronic granulomatous disease of childhood and other known defects of neutrophil function.     

Development of acute erythroleukemia in B-cell immunoproliferative disorders after prolonged therapy with alkylating drugs

The increased incidence of acute myeloblastic leukemia and its variants in patients treated with radiation therapy has long been known. Over the past few years, a relationship between chemotherapy, especially with alkylating agents, and the subsequent development of acute myeloblastic leukemia has been suspected. An unusual variant of acute myeloblastic leukemia, erythroleukemia, has been recognized in three of our patients with B-cell immunoproliferative disorders treated with alkylating agents for extended periods. Review of previously reported cases of myeloblastic transformation after chemotherapy or radiotherapy suggests an inordinately high incidence of the erythroleukemic variant; however, this is not borne out by statistical analysis. The exact relationship between alkylating drug therapy and the development of acute leukemia remains quite speculative.