LITHIUM INHIBITS THE ACTION OF FLUDROCORTISONE ON THE KIDNEY

A patient with autoimmune Addison's disease treated with hydrocortisone and fludrocortisone became mineralocorticoid-deficient whilst taking lithium carbonate for a bipolar illness. During an in-patient metabolic balance study she required 1.0 mg fludrocortisone daily and dietary sodium supplementation to make plasma renin activity and serum potassium normal, and to abolish postural hypotension. We present data to suggest that lithium carbonate inhibits the action of fludrocortisone on the distal renal tubule.     

Invasive cribriform carcinoma of the breast†

A histological review of 1003 invasive breast carcinomas identified 51 tumours in which the invasive component showed a predominantly cribriform pattern. These separated into two groups; 35 which showed exclusively cribriform or cribriform with a limited extent of tubular invasive elements only, designated ‘classical’ invasive cribriform carcinoma and 16 which also contained areas of less well differentiated invasive carcinoma, designated ‘mixed’ invasive cribriform carcinoma. At follow-up, 10 to 21 years after diagnosis, none of the 35 patients with classical invasive cribriform carcinoma had died as a result of this initial carcinoma and 30 remained alive. Of the 16 remaining patients, whose tumours showed areas of less well differentiated carcinoma, only six remained alive. However, the adjusted 10 year survival rate of these patients in this mixed group was significantly better than that of invasive carcinoma in Edinburgh. Invasive cribriform carcinoma in its classical form, is a histological subgroup of invasive carcinoma with the same excellent prognosis as that of invasive tubular carcinoma.     

VALIDATION OF CORONARY HEART DISEASE HOSPITAL DISCHARGE DATA

Data from a 1983 Auckland coronary heart disease register applying current World Health Organization criteria have been used to validate routine hospital discharge data. The register contained 905 patients under 65 years admitted to hospital and 858 of these patients were matched with hospital discharge records. Of the registered definite myocardial infarction cases 86% received the International Classification of Diseases code 410 (acute myocardial infarction); 9% of these cases received a code 411-414 (other forms of coronary heart disease or angina) and 5% received other codes. Only 405 of the 604 cases (67%) coded 410 in the hospital discharge data were true definite myocardial infarctions according to the World Health Organization criteria. The routine hospital International Classification of Diseases data do not provide diagnostic groups sufficiently close to World Health Organization categories for them to be used alone to monitor trends in coronary heart disease morbidity rates.     

The role of progenitor cells in repair of liver injury and in liver transplantation

There are three levels of cells in the hepatic lineage that respond to injury or carcinogenesis: the mature hepatocyte, the ductular "bipolar" progenitor cell, and a putative periductular stem cell. Hepatocytes are numerous, and respond rapidly to liver cell loss by one or two cell cycles but can only produce other hepatocytes. The ductular progenitor cells are less numerous, may proliferate for more cycles than hepatocytes, and are generally considered "bipolar," i.e., they can give rise to biliary cells or hepatocytes. Periductular stem cells are rare in the liver, have a very long proliferation potential, and may be multipotent. Extrahepatic (bone marrow) origin of the periductular stem cells is supported by recent data showing that hepatocytes may express genetic markers of donor hematopoietic cells after bone marrow transplantation. These different regenerative cells with variations in potential for proliferation and differentiation may provide different sources of cells for liver transplantation: hepatocytes for treatment of acute liver damage, liver progenitor cell lines for liver-directed gene therapy, and bone marrow-derived cells for chronic long-term liver replacement. A limiting factor in the success of liver cell transplantation is the condition of the hepatic microenvironment in which the cells must proliferate and set up housekeeping.     

CUTANEOUS MYIASIS FOLLOWING TRAVEL TO BELIZE

Two days after returning from Belize, a 70-vear-old man developed three nonhealing ulcers with serosanguinous drainage on the right posterior ankle. He recalled mildly pruritic "mosquito bites" on the ankles prior to leaving Belize, but no evidence of skin breakdown. Tbe patient denied fever, chills, or other systemic symptoms associated witb his skin lesions.
A one-week course of cephalexin, 500 mg po q.i.d., given for "superficial cellulitis," failed to improve the plaque on the right ankle. The patient was evaluated in the dermatology department 4 weeks after his return from Belize with no progression of the ankle lesions. The examination showed a 4 x7 cm indurated, nontender, erythematous plaque with three sinuses draining serosanguinous fluid (Fig. 1).
A skin biopsy was performed on an area containing a draining sinus tract and submitted for routine and special stains. Tissue and wound cultures were negative for bacteria (aerobic and anaerobic), fungi, mycobacteria, and Leishmania .
Histopathologic Findings : The deep retlcular dermis and subcutis showed an extensive, polymorphous, inflammatory reaction surrounding a parasitic structure that measured 1.8 mm in diameter (Fig. 2). The parasite had a thick eosinophilic cuticle with striated muscle visible around the out-lines of the alimentary tube and other organs (Fig. 3). The morphologic appearance of the parasite was consistent with the larva of a fly, most likely of the Dermatobia species.
Clinical Course : Conservative treatment with polymyxin B sulfate-bacitracin zinc ointment and ace wrap occlusion for 2 days resulted in the extraction of two mature larvae (Fig. 4). The patient reported the sensation of "movement" within the sinuses immediately prior to larval extraction. The third larval specimen was contained in the skin biopsy tissue. All three sites of larval penetration showed rapid healing following the extraction of the larvae.     

Lichen sclerosus et atrophicus of the scalp

A patient is described who developed pruritic lesions of the scalp with increasing hair loss and plaque formation over a period of 15 years, in association with patches if white atrophic skin on her trunk and vulva in the last 5 years. Biopsies of the scalp and trunk lesions both showed lichen sclerosus et atrophicus. This would appear to be the first recorded case of lichen sclerosus et atrophicus of the scalp in the English literature.