Cases from the Osler Medical Service at Johns Hopkins University. Herpetic keratitis

Presenting features

A 38-year-old man with a history of intravenous drug use was admitted to the hospital for treatment of an arm abscess. He noted that his right eye was “blood shot” and painful, but denied recent ocular trauma. He had photophobia and felt that his vision had become worse. Physical examination revealed a red right eye; there was hyperemia of the conjunctiva without surrounding vesicles, and the cornea was cloudy (Figure 1). Visual acuity was normal in the left eye but decreased (20/200) in the right eye. Fundoscopic examination was otherwise unremarkable. The rest of the physical examination was normal except for a tender painful swelling and cellulitis on the left forearm. Laboratory findings revealed antibodies to human immunodeficiency virus (HIV).What is the diagnosis?     

Cases from the Osler Medical Service at Johns Hopkins University: cardiac valvular lesions in Wegener's granulamatosis

Presenting features

A 65-year-old man presented to the emergency department with hemoptysis and hematuria. During the preceding 3 weeks, he had developed fevers, weakness, and myalgias that were increasingly debilitating. He subsequently developed frank hemoptysis and gross hematuria over 3 days. He denied contact with persons who were ill, recent travel, or dental procedures. His past medical history was unremarkable except for elevated serum cholesterol levels, for which he had been taking simvastatin for many years.On presentation, he was acutely ill, with a temperature of 38.8°C, a pulse of 90 beats per minute, a blood pressure of 132/88 mm Hg, and a respiratory rate of 18 breaths per minute. Examination of the head and neck revealed episcleritis and no oral ulcers. Examination of the heart was normal. Chest examination demonstrated bilateral coarse breath sounds with diffuse rhonchi. Skin examination revealed palpable purpura over the extensor surface of the right elbow.Laboratory studies included the following values: serum urea nitrogen, 158 mg/dL; creatinine, 11.7 mg/dL; total leukocyte count, 16.1 × 10³/mL; and erythrocyte sedimentation rate, >130 mm/h. Urinalysis was notable for 35 red blood cells per high-power field. A chest radiograph showed patchy infiltrates in the right upper and lower lobes. An electrocardiogram (ECG) revealed normal sinus rhythm at a rate of 94 beats per minute with normal intervals.The patient was admitted to the hospital with a presumptive diagnosis of vasculitis. He was treated with broad-spectrum antimicrobial agents, prednisone, and cyclophosphamide, in addition to beginning hemodialysis. Antimicrobial therapy was discontinued when blood cultures remained negative at 48 hours. The clinical diagnosis of Wegener’s granulomatosis was confirmed by an antinuclear cytoplasmic antibody titer of 1:80 and antiproteinase 3 (PR3) antibodies of 143 units (positive >30 units). A skin biopsy specimen demonstrated a small vessel vasculitis consistent with the diagnosis.The patient’s symptoms improved gradually, and he was discharged on day 13 with outpatient hemodialysis. During the next 3 days, his strength increased, and he was able to walk longer distances. On the fourth day after discharge, he suffered a ventricular tachycardic arrest at the initiation of hemodialysis. He was admitted to the intensive care unit after a prolonged resuscitation effort, but he remained unresponsive. His ECG was unchanged, and troponin I assay did not suggest myocardial infarction. Blood cultures remained negative. A transthoracic echocardiogram demonstrated normal left ventricular function and no valvular abnormalities. After 10 days, he showed no neurologic improvement. The family decided to withdraw ventilatory support, and he died quickly.What is the diagnosis?     

A prospective randomized trial comparing clomiphene citrate with tamoxifen citrate for ovulation induction

OBJECTIVE: To compare the rates of ovulation and pregnancy after tamoxifen citrate (TMX) or clomiphene citrate (CC) among anovulatory women with infertility. DESIGN: Prospective randomized trial. SETTING: Infertility clinic in a university teaching hospital. PATIENT(S): Eighty-six anovulatory women under 40 years of age undergoing ovulation induction. INTERVENTION(S): The women were assigned randomly to receive either TMX or CC on cycle days 5-9. MAIN OUTCOME MEASURE(S): Rates of ovulation and pregnancy for the two treatment modalities. RESULTS(S): The overall rate of ovulation in the TMX group was 50 of 113 (44.2%) and in the CC group, 41 of 91 (45.1%). There were 10 pregnancies in the TMX group and 6 pregnancies in the CC group. The cycle fecundity per ovulatory cycle was 20.0% in the TMX group and 14.6% in the CC group. CONCLUSION(S): The overall rate of ovulation and pregnancy were similar with TMX and CC. TMX is a suitable alternative agent to CC in the management of anovulatory infertility.     

Levonorgestrel concentrations during 7 years of continuous use of Jadelle contraceptive implants

Serum levonorgestrel concentrations were assayed in a multicenter, 7-year study of 199 users of Jadelle rod implants. We examined drug levels, patterns of changes, factors affecting drug levels, and concentrations at which pregnancies occurred. Mean levonorgestrel concentrations declined from 435 pg/mL at 1 month of use to 64% of that value (280 pg/mL) at the end of 3 years. Between the end of the third and fifth years neither mean nor median serum levels varied markedly. At 5 years the mean concentration was again 64% of the first month's mean. Declining levels were observed thereafter through the end of 7 years when the mean, 224 pg/mL, was 52% of the 1-month value. Last measured drug concentrations of women who became pregnant during Jadelle use had mean and median values of 152 and 144 pg/mL, respectively, and a maximum value of 180 pg/mL. Analyses indicated ponderal index, body weight, duration of use, and a single clinical center were the most important variables affecting measured levonorgestrel levels. Approximately one-third of assays in the sixth and seventh years were found to be below 180 pg/mL, suggesting that Jadelle levonorgestrel implants would not maintain sufficiently high levels of effectiveness against pregnancy after 5 years and that heavier women would then be at greater risk of pregnancy.     

Mifepristone for preinduction cervical ripening beyond 41 weeks' gestation: a randomized controlled trial

OBJECTIVE: To compare the effect of mifepristone with placebo on cervical ripening before labor induction in prolonged pregnancies. METHODS: One hundred eighty women with pregnancies beyond 41 weeks and undilated, uneffaced cervices were assigned randomly to receive mifepristone 200 mg or placebo and observed for 24 hours. We then gave intravaginal misoprostol 25 microg every 4 hours or intravenous oxytocin. We expected 60% of placebo-treated and 80% of mifepristone-treated women to deliver vaginally within 48 hours. RESULTS: Among 180 subjects, 97 received mifepristone and 83 received placebo. The mean interval (+/- standard deviation [SD]) from start of induction to delivery was 2209 +/- 698 minutes for mifepristone-treated subjects and 2671 +/- 884 minutes for placebo-treated subjects (P <.001, log-transformed data). Twelve (13. 6%) mifepristone-treated women and seven (10.8%) placebo-treated women delivered vaginally on day 1 (P =.60). After 24 hours, the median Bishop score for both groups was 3 (0-11) (P =.51). One hundred thirty-one subjects required misoprostol, 65 (67.0%) were mifepristone-treated women, and 66 (79.5%) placebo-treated women (P =.06). The median (range) oxytocin dose was 871.5 (0-22,174) mU for mifepristone-treated women and 2021.0 (0-24,750) mU for placebo-treated women (P =.02). Seventy-seven (87.5%) mifepristone-treated women and 46 (70.8%) placebo-treated women delivered vaginally 48 hours after the start of treatment (P =.01). There were nine cesareans in the mifepristone group and 18 in the placebo group (P =.02). More nonreassuring fetal heart rate patterns and uterine contractile abnormalities occurred in mifepristone-treated subjects. There were no statistically significant differences in neonatal outcomes between groups. CONCLUSION: Mifepristone had a modest effect on cervical ripening when given 24 hours before labor induction, appearing to reduce the need for misoprostol and oxytocin compared with placebo.     

The coastal environment and human health: microbial indicators,pathogens, sentinels and reservoirs

Innovative research relating oceans and human health is advancing our understanding of disease-causing organisms in coastal ecosystems. Novel techniques are elucidating the loading, transport and fate of pathogens in coastal ecosystems, and identifying sources of contamination. This research is facilitating improved risk assessments for seafood consumers and those who use the oceans for recreation. A number of challenges still remain and define future directions of research and public policy. Sample processing and molecular detection techniques need to be advanced to allow rapid and specific identification of microbes of public health concern from complex environmental samples. Water quality standards need to be updated to more accurately reflect health risks and to provide managers with improved tools for decision-making. Greater discrimination of virulent versus harmless microbes is needed to identify environmental reservoirs of pathogens and factors leading to human infections. Investigations must include examination of microbial community dynamics that may be important from a human health perspective. Further research is needed to evaluate the ecology of non-enteric water-transmitted diseases. Sentinels should also be established and monitored, providing early warning of dangers to ecosystem health. Taken together, this effort will provide more reliable information about public health risks associated with beaches and seafood consumption, and how human activities can affect their exposure to disease-causing organisms from the oceans.     

Disappearance of human chorionic gonadotropin and resumption of ovulation following abortion.

The disappearance of human chorionic gonadotropin (hCG) and resumption of pituitary ovarian function was investigated in 13 patients following first- and second-trimester abortions. First-trimester abortion patients (with suction curettage) had a mean time of 37.5 +/- 6.4 days for the clearance of hCG to a level of 2 mlU/ml. Second trimester abortions (with prostaglandin) had a mean time of 27.4 +/- 4.8 days. Patients undergoing second-trimester hysterectomy had a mean disappearance time of 39.7 +/- 5.3 days and only 12 days if the hysterectomy was initiated with ligation of the uterine and ovarian vessels. No significant difference in clearance time was found when it was compared on the basis of the baseline hCG levels. Based on a concomitant luteinizing hormone (LH) and follicle-stimulating hormone (FSH) peak, nine of 12 patients resumed normal pituitary function. These LH and FSH peaks were seen even though the serum hCG levels were as high as 35 mlU/ml. Based on serum progesterone levels of greater than 3 ng/ml, all these nine patients ovulated as early as 21 days after abortion. In view of these results, the clearance of hCG after pregnancy termination depends mainly upon the type of procedure used. Moreover, in view of the early time of ovulatory recovery, contraception should be instituted within the first 2 weeks following pregnancy termination.