MR shoulder arthrography in patients younger than 40 years of age: Frequency of rotator cuff tear versus labroligamentous pathology

The purpose of this study was to compare the frequency of rotator cuff pathology versus labroligamentous pathology in patients younger than 40 years and to determine whether routine MR arthrography is justified in all patients in this age group, regardless of the clinical symptoms. The MR arthrography was carried out on 332 patients 40 years of age and younger. Two hundred and forty‐three patients had clinical history of instability and possible labroligamentous pathology. Eighty‐nine patients had no history or physical signs of instability and were referred for reasons other than instability, such as assessment for rotator cuff tear. In the 243 patients younger than 40 years with clinical history of potential labral pathology, 39% (95/243) showed a labral tear and 2.1% (5/243) had a full‐thickness rotator cuff tendon tear. In the 89 patients with no history suggesting labral pathology, 19% (17/89) showed an unsuspected labral tear and 4.5% (4/89) had a full‐thickness rotator cuff tear. These findings suggest that, regardless of the clinical indication for referral, patients aged 40 and less referred for shoulder MRI should be imaged using MR arthrography because of the significant risk that symptoms are related to unsuspected labral pathology.     

Comparative studies of different gliadin preparations in detecting antigliadin antibodies

Antigliadin antibodies (AGA) have been used as indicators of celiac disease. The presence of these antibodies in other gastrointestinal and liver disorders and even in normal healthy controls casts a shadow on the diagnostic significance of AGA. We examined 91 normal controls of varying ages and 97 patients with various gastrointestinal and liver disorders. Forty-eight of 97 nonceliac patients were positive for AGA, and diagnosis-specific incidences ranged as high as 75% in patients with small bowel disease. In addition, the levels of AGA were dependent upon age as their presence increased from 12% in children with a mean age of 10, to 35-40% in normals within the 60-70 age group. The lack of celiac disease specificity of AGA was not due to either the source of gliadin nor to the sensitivities of the test methods. Both the enzyme-linked immunosorbent assay (ELISA) and the immunofluorescence methods gave comparable results. ELISA was more sensitive than immunofluorescence. These results thus strongly suggest that AGA are not markers of celiac disease and increase with age in normals.     

A nonfatal case and 2 fatal cases of paraneoplastic pemphigus: can a complement indirect immunofluorescent test help to identify fatal "group A" paraneoplastic pemphigus cases?

We studied 3 recent cases of paraneoplastic pemphigus (PNP) in detail. Two patients died despite concerted management efforts. One patient received no treatment after the appearance of PNP and recovered completely from both PNP and lymphoma. Multiple serum studies of these 3 patients plus 9 other proven PNP cases revealed that 8 of 9 fatal PNP cases (referred to here as "group A") had distinctive cell surface antibodies detected by complement indirect immunofluorescent (CIIF) tests on monkey esophagus sections. By contrast, none of the sera from 3 patients with PNP who experienced long-term survival (referred to here as "group B") and none of 20 pemphigus vulgaris or 10 pemphigus foliaceus control sera revealed similar beaded cell surface CIIF reaction patterns, a difference that is statistically significant (P <.0001). Cell surface CIIF reaction patterns of group A PNP antibodies resemble the pattern of pemphigus antibody reactions in indirect immunofluorescent tests on the same substrate; however, the latter tend to be thinner and more linear, whereas the cell surface CIIF pattern tends to be more beaded, suggesting possible desmosomal reactions. We believe this test is useful in identifying an aggressive group A form of PNP.     

Pemphigus antibody action on skin explants: kinetics of acantholytic changes and stability of antigens in tissue cultures of normal monkey skin explants.

The pathogenic effect of the intercellular antibodies of pemphigus was studied by using organ culture of monkey skin. Skin explants that were grown on sera with intercellular antibody titers of 320 or greater fixed these antibodies within one day as demonstrated by direct immunofluorescence for IgG. None of the control sera gave such staining patterns. Following the binding of intercellular antibodies, characteristic histologic changes appeared, notably separation of individual epidermal cells and acantholysis. These histologic changes became more marked in two to five days. During this period, the bound antibodies and the intercellular antigens decreased and disappeared. These temporal relationships of immunofluorescence and histologic findings suggest that pemphigus antibodies play a role in the induction of acantholysis.     

Studies in immunodermatology. VI. IF studies of autoantibodies to the stratum corneum and of in vivo fixed IgG in stratum corneum of psoriatic lesions.

Indirect immunofluorescent (IF) tests on sections of normal human skin reveal the presence of antibodies to the stratum corneum in most normal human sera. Sera absorbed with hyperkeratotic scales gave negative reactions. These reactions appeared to correspond to those of the stratum corneum antibodies which were first detected by Krough and Tonder by immune adherence, though this remains to be documented since the conjugate alone stained the stratum granulosum in a pattern comparable to that of the IF staining reported by Krough. The staining was caused by conjugates with high but not by those with low fluorescein to protein ratios. In indirect IF tests, comparable titers of stratum corneum antibodies were found in sera of psoriasis patients and control subjects. Since they reacted with the stratum corneum of the antibody producer they are referred to as autoantibodies. Direct IF tests of psoriatic lesions revealed the presence of in vivo bound IgG as well as other immunoglobulins and complement in the stratum corneum. To differentiate staining with conjugated protein from direct and indirect IF staining of the stratum corneum a four-compartment test was devised. Skin sections were treated with saline or with stratum corneum antibodies and then with conjugates without (compartments 1 or 2) or with (compartments 3 or 4) anti-IgG antibodies. Sections were read by the method of Kawamura and his associates with both UV and BV illumination. Compartment 3 is a direct IF test and compartment 4 is an indirect IF test. In four-compartment tests performed on both biopsies of psoriatic lesions or scales the difference between compartments 1 or 2 and 3 affords a measure of in vivo bound IgG and the difference between compartments 3 and 4 provides information on the presence of free stratum corneum antigen. With this four-compartment test system it was found that in vivo fixation of IgG occurs in the intercellular areas of the stratum corneum of psoriatic lesions or scales and that this corresponds to the site of binding of the stratum corneum autoantibodies. This in vivo binding of IgG in the stratum corneum of psoriatic lesions resembles somewhat the intercellular fixation of IgG in the stratum spinosum in pemphigus. In the materials examined in these preliminary studies most, if not all of the stratum corneum antigen appeared to be covered with in vivo bound IgG.     

Gustatory function in chronic inflammatory middle ear diseases

HYPOTHESIS: Changes of gustatory function after ear surgery have been studied extensively. However, little is known on the influence of repeated/chronic inflammation within the middle ear on taste. STUDY DESIGN: Prospective study. MATERIALS AND METHODS: Forty-six patients suffering from either cholesteatoma (n = 25) or chronic otitis media mesotympanalis (n = 21) received quantitative gustatory tests. None of these patients had been operated on before these investigations. RESULTS: Side by side comparison showed a significantly lower taste function on the anterior two thirds of the tongue ipsilateral to the site of inflammation, regardless of the diagnosis. Further analyses exhibited a trend toward greater impairment in relation to the severity of the inflammatory process. CONCLUSION: These data are proof that taste function changes in relation to chronic middle ear diseases. It further shows that many of these alterations go unnoticed by the patients.     

Pemphigus, pregnancy, and plasmapheresis

Pemphigus vulgaris (PV) is an autoimmune blistering disorder that usually occurs in the fifth and sixth decades of life but may occur at younger ages and during pregnancy. Circulating intercellular antibodies directed at desmosomal proteins may cross the placenta and place children at risk for neonatal pemphigus (NP). We describe the case of a pregnant woman with PV treated successfully with a combination of systemic corticosteroids and plasmapheresis. The possibility of PV should be considered in any pregnant woman with a worsening, widespread, mucocutaneous, blistering disease. Plasmapheresis offers a useful alternative to immunosuppressive therapy in the setting of pregnancy.