Candida arthritis. A manifestation of disseminated candidiasis.

Fungal infections infrequently involve the joints. Review of the literature reveals that Candida arthritis is rare, that it is usually a complication of disseminated candidiasis and that it occurs as a primary joint infection without spread from adjacent osteomyelitis. In the patient we describe Candida arthritis and bursitis of separate joints developed as a late manifestation of disseminated infection following "transient" C. tropicalis fungemia. Treatment consisting of aspiration and parenteral amphotericin B eradicated the joint infection without the need for surgery. Bursectomy, however, was required to eradicate the bursal infection. Awareness of this as well as other late complications of candidemia which signify disseminated infection is important. Optimal therapy will be determined only by further clinical experience with this unusual manifestation of Candida infection.     

Recovery of adrenal reserve following treatment of disseminated South American blastomycosis

South American blastomycosis commonly involves the adrenal glands as proved in autopsy series, although clinical adrenocortical insufficiency is infrequently suspected. In 1972, an Ecuadorian man was seen with disseminated paracoccidioidomycosis and Addison's disease documented by low basal steroid levels and lack of response to ACTH therapy. The patient has since been treated with a total dose of 4,000 mg of amphotericin B. He discontinued all steroid replacement therapy for two years but remained asymptomatic. Recent evaluation documented improvement in basal steroid production, particularly mineralocorticoids. Adrenal reserve has also been demonstrated by the response of glucocorticoids to ACTH stimulation. This is the first well documented case in which adrenal reserve was recovered following treatment of granulomatous Addison's disease.     

The protean manifestations of Mycoplasma pneumoniae infection in adults.

Mycoplasma pneumoniae is a well recognized respiratory pathogen in children and young adults. In addition, M. pneumoniae infections may also involve other organ systems. Reviewed here are the various clinical syndromes in adults caused by this infectious agent, with emphasis on those which have recently been seen at The New York Hospital. Two previously unreported manifestations of M. pneumoniae infection, cranial nerve mononeuropathy and hepatitis, are described, and the laboratory methods for diagnosis are discussed.     

Serious infections caused by Streptococcus milleri

Viridans streptococci continue to be the most common etiologic agents in bacterial endocarditis. The spectrum of diseases other than endocarditis caused by these organisms, however, has received sparse attention. Moreover, little clinical information is available concerning the individual viridans streptococcal species. During the 16 months of this study, one species of viridans streptococci, Streptococcus milleri, caused a surprising number of clinically significant suppurative infections. Clinical syndromes included the following: abscesses, 10 cases; peritonitis, four cases; endocarditis, three cases; cholangitis, empyema and cellulitis, one case each. A gastrointestinal source was apparent in eight of these 20 cases. Review of 58 cases of viridans streptococcal endocarditis demonstrated that although Strep. milleri was an infrequent cause of endocarditis, this species was associated with an unusual frequency of suppurative complications. Our experience suggests that Strep. milleri may be more commonly associated with serious suppurative infections than other viridans streptococci and that species identification may be a clinically useful procedure.     

Effects of auriculin (atrial natriuretic factor) on blood pressure, renal function, and the renin-aldosterone system in dogs

Auriculin is a potent vasoactive and natriuretic peptide that was recently isolated and purified from rat atrial tissue. Since this peptide could be of great importance for renal, cardiovascular, and volume homeostasis, its functional properties have been characterized in dogs. The effects of synthetic auriculin on renal function, mean blood pressure, plasma renin activity, renin secretory rate, and plasma aldosterone levels were determined. Auriculin was administered intravenously as a prime (1.0 microgram/kg body weight) and constant infusion (0.1 microgram per minute/kg body weight for one hour) to five anesthetized dogs. In addition, two conscious dogs were used to verify some of the results obtained in anesthetized dogs. Auriculin decreased mean blood pressure from 134 +/- 5 to 122 +/- 4 mm Hg (p less than 0.05, paired t test) and increased glomerular filtration rate (25.5 +/- 2.7 to 32.4 +/- 4.1 ml per minute per kidney, p less than 0.05), diuresis (0.21 +/- 0.03 to 1.06 +/- 0.14 ml per minute per kidney, p less than 0.05), natriuresis (38 +/- 0.6 to 187 +/- 35 mueq per minute per kidney, p less than 0.05), and kaliuresis (14.8 +/- 1.6 to 35.7 +/- 6.3 mueq per minute per kidney, p less than 0.05). These effects were sustained throughout the infusion of auriculin and were entirely reversible. Renal plasma flow increased transiently for one to two minutes, and then returned to or below control levels. Urine osmolality decreased by 40 percent (p less than 0.05) whereas free water clearance remained unchanged (p less than 0.05). Auriculin reversibly decreased plasma renin activity (11.6 +/- 2.3 to 3.6 +/- 1.2 ng/ml per hour, p less than 0.05), renin secretory rate (895 +/- 313 to 255 +/- 28 ng per hour per minute, p less than 0.05), and plasma aldosterone levels (8.4 +/- 1.6 to 3.6 +/- 0.7 ng/dl, p less than 0.05), whereas plasma cortisol levels remained unchanged. These results demonstrate that auriculin has a unique combination of functional properties, increasing glomerular filtration rate, diuresis, and natriuresis, without a sustained increase in total renal blood flow, and lowering blood pressure, plasma renin levels, renin secretory rate, and plasma aldosterone levels. These properties suggest an important potential role for atrial natriuretic peptides in the regulation of renal function, extracellular volume, and blood pressure.     

Hereditary nephritis with a characteristic renal lesion

Light and electron microscopic studies were performed on renal tissue from four involved members of a family with hereditary nephritis.The two females studied had no apparent deafness or renal insufficiency, but a nonspecific mild increase in mesangial matrix was noted on light microscopic examination of the renal biopsy specimen. The two males had neurosensory deafness. One had advanced renal insufficiency with glomerular sclerosis, whereas the other had no azotemia and less histopathologic change.However, all four had a characteristic ultrastructural lesion consisting of glomerular basement membrane splitting separated by clear spaces with the accumulation of small dense particles between the thin layers. This change may be specific for certain forms of hereditary nephritis.     

Absenteeism and labelling in hypertensive subjects: Prevention of an adverse impact in those at high risk

In this work-site population, the illness absenteeism of 259 hypertensive subjects was studied in the year after they were screened and labelled. Absenteeism due to illness increased more in 48 patients who were unaware of their hypertension (newly labelled) than in the 211 subjects who were aware. Among the newly labelled subjects, only the young subjects and those with “pure” systolic hypertension experienced increased absenteeism; the older subjects with diastolic hypertension did not. The newly labelled subjects who received active follow-up and treatment with antihypertensive medication had only minimal increases in absenteeism. In contrast, those who received active follow-up without medication, and those who received only episodic follow-up had significantly greater Increases. Vigorous efforts are warranted to insure active follow-up and treatment for hypertensive subjects after their condition has been labelled. Caution should be exercised in labelling, however, if no antihypertensive treatment is initiated.     

Primary amenorrhea associated with hirsutism, acanthosis nigricans, dermoid cysts of the ovaries and a new type of insulin resistance

We describe a 15 1/2 year old presenting with primary amenorrhea, hirsutism, acanthosis nigricans and insulin resistance. Ovarian vein catheterization studies revealed bilateral excess plasma testosterone and androstenedione secretion, and at surgery multiple dermoid cysts of both ovaries were found in association with polycystic ovaries. The suggestion that the dermoid cysts may be causative in the evolution of the polycystic ovarian disease has been made. The mechanism of the insulin resistance appears to be at the post receptor level. The acanthosis nigricans diminished following surgery with normalization of the plasma androgens.     

Feasibility of maintaining normal glucose profiles in insulin-dependent pregnant diabetic women

This study was designed to test the feasibility of a patient-monitored glucose determination program to establish and maintain normal blood glucose levels. Ten pregnant women, who were insulin-dependent diabetics prior to becoming pregnant and who were in their eighth week or less of pregnancy, were offered the program. All 10 accepted and continued the program for the duration of their pregnancy. Normal plasma glucose (60 to 140; x? = 80 mg/dl) levels were achieved after one week of the program and were maintained throughout the pregnancy as documented by 5 to 8 blood glucose determinations a day. The hemoglobin A_1c level, which was elevated in all 10 patients at the start (9.4 ± 1.6 per cent) of the program, fell into the normal range (2 to 5.0 per cent) five weeks after glucose values became normal. Serum estradiol (0.8 ± 0.6 ng/ml), serum prolactin (10 ± 9 ng/ml) and serum human chorionic gonadotropin (5,500 ± 1,700 ng/ml), although all abnormal at the start of the program, became normal after glucose control was achieved (program weeks 4, 5 and 6, respectively). The infants showed no signs of macrosomnia (2,988 ± 959 g), hypoglycemia, hyperbilirubinemia, hypocalcemia, erythremia or respiratory distress. Therefore, a program to maintain normal blood glucose levels during a diabetic patient's pregnancy is not only possible but may also improve the pregnancy and the outcome.     

The effectiveness of a consultation: Compliance with initial recommendations

To identify the attributes of an effective consultation, 202 general medicine consultations were analyzed to assess the extent of compliance with the consultant's initial recommendations. The overall compliance rate was 77 percent. Compliance decreased as the number of recommendations increased. The consultant made more recommendations among patients who had more complex and more severe illnesses. Although compliance did increase significantly in severely ill patients (p < 0.01), with each severity level, compliance was higher when five or fewer recommendations were made. In fact, compliance decreased from 96 percent in severely ill patients with small consultation lists to 79 percent in those with large lists. Compliance was greatest with recommendations involving medications and least with those requiring direct physician and nursing action. Multivariate analysis confirmed that clinical severity of the patients' illnesses and the type and number of recommendations were all predictors of compliance. To promote overall compliance, consultants should limit the total number of recommendations in their initial consultation to five or fewer, focusing on issues central to current patient care. This is especially true in severely ill patients. Since recommendations that must be implemented by physicians or nurses have a lower compliance rate, consultants must carefully follow up those requests.     

Pericardial tamponade: A major presenting manifestation of hydralazine-induced lupus syndrome

Hydralazine, a frequently prescribed antihypertensive, may produce a syndrome clinically similar to systemic lupus erythematosus. Cardiac manifestations, however, are generally uncommon in hydralazine-induced lupus. We describe the unusual development of pericarditis and pericardial tamponade in a patient treated with hydralazine who demonstrated clinical and laboratory evidence for the drug-induced syndrome. Treatment with prednisolone produced dramatic amelioration of the pericarditis. No recurrent manifestations of the lupus syndrome occurred after cessation of steroid therapy. If signs and symptoms of cardiac disease develop in hypertensive patients receiving hydralazine, the possibility of drug-induced lupus pericarditis should be considered.     

Increased damage after ischemic stroke in patients with hyperglycemia with or without established diabetes mellitus

Animal experiments employing controlled degrees of cerebral ischemia have demonstrated that elevated blood-brain glucose concentrations greatly enhance the extent and degree of subsequent brain damage. The question of whether or not a similar relationship applies in man was examined by retrospectively segregating patients admitted with the diagnosis of ischemic stroke into diabetic (n = 35) and nondiabetic (n = 72) groups. A separate nondiabetic population with ischemic stroke was prospectively analyzed by dividing patients into those with an admission blood glucose level above (n = 14) or below (n = 17) 120 mg/dl. The neurologic status at discharge was used to stratify outcome as good, fair, or poor in the retrospective study. The ability or inability to return to work was used to separate good and poor outcomes in the prospective study. Neurologic outcome in diabetic patients with stroke was significantly worse (p < 0.05) than in nondiabetic patients, and the diabetic patients had a greater (p < 0.05) number of stroke-related deaths. In the prospective study, neurologic outcome also was worse with high blood sugar levels, only 43 percent of the patients with blood glucose values above 120 mg/dl returned to work, whereas 76 percent of those with lower blood sugar values regained employment (p = 0.061).     

Increased urinary enzyme excretion in workers exposed to nephrotoxic chemicals

Nephrotoxic chemicals are commonly present in the environment, particularly in the workplace. The level of occupational exposure to these chemicals has been so reduced that exposure to these agents now rarely causes clinically evident acute renal disease. A sensitive indicator of renal injury, urinary excretion of N-acetyl-beta-glucosaminidase, was utilized to evaluate persons exposed in the workplace to lead, mercury, or organic solvents, for evidence of renal effects from this exposure. None of the persons had clinically evident renal disease by history, none had hypertension, and all had normal findings on urinalysis. When compared with appropriate control populations, workers exposed to lead, workers exposed to mercury, and two of three groups of workers exposed to organic solvents had significant increases in urinary acetyl glucosaminidase activity. The third group of laboratory workers with low exposure to organic solvents had no increase in urinary acetyl glucosaminidase activity. It is concluded that exposure to environmental nephrotoxins at levels currently considered safe can produce renal effects as manifested by elevations of urinary acetyl glucosaminidase excretion. It is speculated that these renal effects are not always innocuous.     

Renal response to mechanical ventilation in patients with chronic hypercapnia

Alkalosis in hypercapneic patients caused by abrupt respirator-induced reduction of the partial pressure of carbon dioxide leads to bicarbonate diuresis. Potassium is the predominant cation accompanying bicarbonate loss in the urine.The determining variable for induction of proportional changes in renal bicarbonate and potassium excretion is the partial pressure of carbon dioxide. The reduction of the partial pressure of carbon dioxide modifies bicarbonate regeneration directly by limiting the hydration reaction and facilitates potassium loss indirectly by reducing extracellular, and by inference intracellular, hydrogen ion activity.     

Lupus erythematosus-like disease due to hydrazine

A case of systemic lupus erythematosus-like disease due to occupational exposure to hydrazine is described. The patient had four of the 1982 revised criteria for SLE (malar rash, photosensitivity, antinuclear antibody, and antibody to nDNA) and genetically is a slow acetylator with the HLA DR2,3 phenotype. Many of her healthy family members had antibodies to nuclear constituents. Lymphocytes from the patient and an identical twin sister, but not from three normal control subjects, showed inhibition of pokeweed mitogenstimulated IgG synthesis after five daily exposures of each subject to hydrazine. Chemicals such as hydrazine in the environment can induce cases of SLE-like disease in predisposed persons.     

Prostaglandins in primary dysmenorrhea: Comparison of prophylactic and nonprophylactic treatment with ibuprofen and use of oral contraceptives

Prostaglandin synthetase inhibitors have been used in clinical trials for the treatment of primary dysmenorrhea on the theory that the disorder may be caused by a high level of prostaglandins. However, a causal role of prostaglandin in dysmenorrhea has not been established, and there is only indirect evidence that the amelioration of dysmenorrhea by prostaglandin synthetase inhibitors is related to their inhibition of prostaglandin synthesis in the uterus. We, therefore, monitored menstrual prostaglandin release in 14 dysmenorrheic patients in a controlled, double-blind, cross-over trial of ibuprofen (Motrin®) and in two dysmenorrheic subjects while they were receiving oral contraceptive therapy and while they were not. A total of 89 menstrual cycles were studied. We found that ibuprofen therapy reduced menstrual prostaglandin release and relieved dysmenorrhea but that placebo therapy did not. Oral contraceptives decreased menstrual flow, reduced prostaglandin release and also alleviated dysmenorrhea. We conclude that primary dysmenorrhea is related to a high level of menstrual prostaglandin release. Ibuprofen inhibits prostaglandin synthesis whereas oral contraceptives inhibit ovulation and cyclic endometrial development. Thus, the two drugs suppress endometrial prostaglandin through different mechanisms. Reduction of menstrual prostaglandin release leads to alleviation of dysmenorrhea.     

General medicine consultation: Lessons from a clinical service

The 564 consultations performed by a general medicine consultation service during its first year were analyzed in order to provide a concrete definition of this new academic domain. Of the consultations, 52 percent were for patients on the surgical service. Among these patients, the most common reason for consultation was the preoperative management of chronic illness, specifically, hypertension, diabetes, and angina; 47 percent of such patients had two or more chronic illnesses. The service recommended cancellation of planned surgery in 2 percent and postponement in 9 percent of the 210 patients seen preoperatively. Patients on the psychiatric service accounted for 47 percent of the consultations. In this group, diagnostic issues were the most common reasons for consultation, that is, abdominal pain, dementia, and the suspicion of thyroid disease. Only 12 percent of the patients were seen for prognostic reasons, usually related to the planned use of electroconvulsive therapy or tricyclic antidepressants. The service was evaluated by the referring physicians who rated the service favorably on its “mechanics,” as well as on its qualitative performance. However, complaints of triviality were voiced when the average length of the list of recommendations seemed disproportionate to the complexity of the problems. The service was also evaluated by the residents who had provided consultations. From their perspective, the service was more successful in teaching the “art” of consultation than the “science.” This experience provides an operational definition of the work facing a general medicine consultation service as well as data useful in focusing future educational programs and research efforts.