Iodine and lithium-induced hypothyroidism. Documentation of synergism

Signs and symptoms of hypothyroidism were noted in a patient receiving lithium carbonate for 2 years as prophylaxis against recurrence of mania and depression. When lithium therapy was stopped, the hypothyroidism resolved; but it recurred with the administration of potassium iodide. When potassium iodide therapy was discontinued, the patient became euthyroid. In a second patient chemical evidence of hypothyroidism (fall in circulating thyroid hormone levels, elevation of serum thyrotropin) was noted after he had received 3 weeks of lithium therapy. With the addition of potassium iodide, laboratory evidence of hypothyroidism became more pronounced, and clinical signs of hypothyroidism developed. All abnormalities resolved promptly following the withdrawal of lithium and iodine. These observations suggest that lithium and iodine can act synergistically to produce hypothyroidism and that the combined use of these agents should be avoided.     

Neisseria subflava endocarditis. Case report and review of the literature

Neisseria subflava is a rare cause of bacterial endocarditis. Only seven cases have been identified in the world literature if strict criteria as to organism classification and of endocarditis are applied to individual case reports. The first reported case in an intravenous drug user is described. In addition, findings on serial two-dimensional and M-mode echocardiography performed during and after the treatment period are presented. This patient's recovery with anti-microbial therapy alone despite evidence of aortic and significant mitral valve involvement is in accord with results of other antibiotic-treated cases.     

Transluminal laser catheter angioplasty

The first transluminal laser angioplasty in animals is reported herein. An Argon laser and a specialized coronary arterial catheter with a fiberoptic wave guide were used. Immediate histologic changes consisted of a moderate degree of intimai necrosis and some loss of elastic tissue. At 5 days the intima was repaired, but focal elastic tissue loss persisted.     

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.     

Extreme hypocapnia in the critically ill patient

Respiratory alkalosis was the most common acid-base disturbance observed in a computer analysis of 8,607 consecutive arterial blood gas studies collected over an 18 month period in a large intensive care unit.Through a retrospective review of the randomly selected hospital records of 114 patients, we defined four groups based upon arterial carbon dioxide tension (PaCO₂) and mode of ventilation. Group 1, with a PaCO₂ of 15 mm Hg or less, consisted of 25 patients with an over-all mortality of 88 per cent. Group II, with a PaCO₂ of 20 to 25 mm Hg, consisted of 35 patients with a mortality of 77 per cent. Group III, with a PaCO₂ of 25 to 30 mm Hg, consisted of 33 patients with a mortality of 73 per cent, and Group IV, with a PaCO₂ of 35 to 45 mm Hg, consisted of 21 patients with a mortality of 29 per cent (p <0.001). Shock and sepsis were most common in group I patients.These findings suggest that extreme hypocapnia in the critically ill patient has serious prognostic implications and is indicative of the severity of the underlying disease.     

Bacteroides fragilis resistant to the administration of clindamycin.

The susceptibility of Bacteroides fragilis to the administration of clindamycin, and the efficacy of this agent in Bacteroides infections are well documented. Clindamycin-resistant strains of B. fragilis were isolated from two patients with bacteremia at two institutions. Clinically significant resistance to clindamycin therapy has not been noted previously in B. fragilis infections.     

Accidental hypothermia in an alcoholic population

Thirty-nine cases of accidental hypothermia are reviewed. Data indicate that mortality varies with the presence of underlying disease rather than with the degree of hypothermia or the methods of rewarming. In 31 patients with hypothermia alone (average temperature 85 °F) mortality was 6.25 per cent. In eight patients with hypothermia and another primary condition (average temperature 84 °F) mortality was 75 per cent.Intractable cardiac arrhythmia has been reported as the primary cause of death in hypothermia. In these patients, death during hypothermia resulted from pulmonary complications. Ventricular arrhythmias, when they occurred, were responsive to routine measures such as electrical cardioversion and myocardial suppressant drugs. Methods of treatment are discussed.     

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.     

Acute cortical necrosis. Case report and review of the literature

Confluent acute cortical necrosis is a rare but catastrophic disease. Described here is one case which was heralded by abruptio placenta and occurred in concert with a disseminated intravascular coagulopathy (DIC). All causes of acute cortical necrosis share one common denominator: a procoagulant factor capable of activating the coagulation mechanism. This aspect of the pathogenesis, the pathophysiology and clinical aspects of acute cortical necrosis are reviewed and contrasted to acute tubular necrosis and irreversible postpartum renal failure. Preparation for an extended period of treatment is emphasized as recovery from acute cortical necrosis is protracted.     

The cardiologist's responsibility for preventing coronary heart disease.

The recent increase in coronary heart disease is real and the causes must mainly be environmental. Consequently the condition should largely be preventable. The application of what is already known is likely to be a far more effective way of reducing the mortality rate than all attempts at palliative treatment, but vigorous action will be necessary. Much greater sums are being expended on coronary-care units and cardiac surgery than in preventing the need for them, although there is little evidence that they have significantly lowered the over-all mortality rate. Conventional treatment is immensely expensive. Prevention could in the long run be much cheaper. Cardiologists on their own are unlikely to succeed in a program of prevention. They need the help of many others, including community nurses, nutritionists, public health workers, sociologists, and of course general practitioners, but they have responsibility for leadership and for providing background knowledge. For the detection of certain risk factors, health examinations are necessary and should be part of general practice. Also, advice is best given on an individual basis. The chief-known risk factors (hyperlipidemia, hypertension, smoking, physical inactivity) could be controlled. CHD occurs in adults but atherosclerosis starts many years before. Prevention should begin with appropriate infant feeding, whenever possible with breast milk, and continue into childhood, when habits are formed and attitudes to life can best be influenced. It should be possible to bring up children virtually free from risk factors. It may never be possible to prove the effectiveness of such a multifactorial program by prospective controlled intervention studies, but the evidence indicates strong probability. The stakes are too high to delay action any longer. Physicians daily give advice in areas where the evidence is much less certain. Such a program for the control of coronary artery disease is urgently needed and could become one of the most rewarding activities for the medical profession.     

Central nervous system disease in systemic lupus erythematosus: Therapy and prognosis

The effect of corticosteroid therapy in 28 patients with 52 episodes of neuropsychiatric disease in systemic lupus erythematosus (SLE) was evaluated. Categories of organic central nervous system disease were seizures (eight patients), organic brain syndromes (nine patients), aseptic meningitis (four patients) and a variety of focal neurologic findings (seven patients). Fourteen patients had 15 episodes of functional psychosis without other evidence of neurologic disease.Although there was a general correlation between clinical and serologic evidence of active SLE and the development of organic neurologic disease, there was no evidence that therapy with very large doses of corticosteroids was beneficial. Of the deaths in this series, two were due to probable active SLE involving the central nervous system whereas five were attributable to complications of therapy. The long-term morbidity, likewise, was high in the patients who received large doses of corticosteroids. In all, 12 patients had major complications of corticosteroid therapy.Functional psychosis was usually precipitated by corticosteroid therapy and responded to a reduction in steroid dosage and administration of psychotropic drugs.     

Intraoperative 2-dimensional echocardiography: Ejection of microbubbles from the left ventricle after cardiac surgery

Although the presence of entrapped air in the left ventricle at surgery has long been a concern, its prevalence and clinical significance are unknown. Two-dimensional echocardiography provides a unique means for observing intracardiac microbubbles intraoperatively. Accordingly, intraoperative 2-dimensional echocardiograms obtained in 79 patients immediately after cardiopulmonary bypass were examined for the presence of microbubbles. Left ventricular microbubbles were detected in 14% of coronary artery bypass operations (n = 22), 50% of multiple valve replacements (n = 8), 67% of single valve replacements (n = 58), and 100% of atrial septal defect closures (n = 4), left atrial myxoma resections (n = 2), and mitral commissurotomies (n = 2). Microbubbles were not observed in patients undergoing coronary artery bypass with valve replacement (n = 4) or with removal of left ventricular aneurysm (n = 1). Continuous ejection of microbubbles from the left ventricle was frequently noted for extended periods of time and, although no patient in this study showed evidence of gross neurologic dysfunction, the possibility of subclinical organ damage exists. We conclude that 2-dimensional echocardiography is useful for detection of intracardiac microbubbles and therefore may be instrumental in their elimination.     

Heart failure 63 years after traumatic arteriovenous fistula

Congestive heart failure developed in a patient 63 years after an initial bullet wound, sustained at age 12, and a subsequently acquired arterlovenous fistula of the left thigh. This is the longest reported interval between formation of an acquired arterlovenous fistula and development of cardiac decompensation. Clinical improvement after surgical closure of the fistula was dramatic. Objective evidence of improvement was documented with serial echocardiograms.     

Familial renal amyloidosis: Case reports and genetic studies

Rapidly progressive biopsy-proved renal amyloidosis developed in three brothers, aged 49, 52, and 55, of Irish-American origin. None had evidence of a plasma cell dyscrasia, a monoclonal serum or urine protein, or any underlying chronic disease, immunoperoxidase staining of one pulmonary and one renal biopsy specimen was negative for Amyloid A (AA), Amyloid L (AL), and prealbumin. To investigate factors that might play a role in the disease, the subjects and 21 relatives were typed for antigens of the A, B, C, and DR loci and the linked marker genes for factor B and glyoxalase. The ability of macrophages to degrade serum amyloid A (SAA) [1] was examined. One brother yielded an intermediate AA-like product similar to what is seen in most patients with AA or AL amytoldosis and 40 percent of normal subjects. The other two degraded SAA completely to small peptldes. Analysis of the families revealed first that the disease was not linked to the major histocompatibility complex. We were unable to demonstrate a genetic relationship between processing of SAA by peripheral mononuclear cells and the human leukocyte antigen locus. Finally, the pattern of SAA degradation was not associated with the development of the disease.     

Hemoglobin S/C disease in a pregnant woman with crisis and fat embolization syndrome

The complications of painful crisis and megaloblastic anemia are hallmarks of the pregnant patient with hemoglobin S/C disease. We describe here the clinical course in a patient with hemoglobin S/C disease in whom painful crisis and the fat embolization syndrome developed postpartum with severe neurologic abnormalities. Response to exchange blood transfusion was dramatic, and the patient recovered without neurologic impairment.