27-jähriger Reiserückkehrer mit hohem Fieber und septischem Schock im Verlauf

A 27-year-old man was admitted with high fever and shivers eleven days after returning from vacation in Indonesia. Physical examination, laboratory values, abdominal ultrasound, and chest x-ray were not conclusive. All blood cultures yielded growth of Salmonella enterica serovar Typhi, and typhoid fever was diagnosed. Subsequently, the patient developed septic shock and pulmonary edema.In this case report epidemiological, clinical, and therapeutic aspects of typhoid fever are discussed with special emphasis on criteria for severe typhoid fever, which is treated with additional glucocorticoids.     

Anxiety in medically III patients

Anxiety disorders and anxiety symptoms are highly prevalent in the general population and more so in the medically ill. They have a number of negative consequences for these patients and may worsen the outcome of the medical illness and increase health care utilization. In the evaluation of these patients, it is of paramount importance to identify the etiology of the anxiety and, in particular, to differentiate primary from secondary anxiety. Management includes medications (especially benzodiazepines and selective serotonin reuptake inhibitors) and psychotherapy (particularly cognitive-behavioral therapy).     

Monocyte chemotactic protein expression during schistosome egg granuloma formation. Sequence of production, localization, contribution, and regulation.

The present study explored the role of murine monocyte chemotactic protein (MCP) in the T cell-mediated hypersensitive granulomatous response to Schistosoma mansoni eggs. The study examined the time course of local production, contribution to cellular infiltration, and the role of T cells in endogenous regulation. Synchronized pulmonary granulomas were induced under conditions of primary and secondary states of immunity. Primer-directed polymerase chain reaction analysis showed increased MCP mRNA expression in granulomatous lungs, mainly in the secondary response. Levels of MCP were measured by enzyme-linked immunosorbent assay in cultures of intact granulomas. Spontaneous MCP production was modest in primary granuloma cultures, reaching a maximum of 5.7 +/- 0.9 ng/ml by 16 days. In contrast, the secondary response showed augmented and accelerated production, achieving 13 +/- 2.0 ng/ml by 2 days. Immunohistochemical staining revealed the strongest MCP expression within microvascular adventitial cells or pericytes as well as in scattered mononuclear cells associated with granulomas. Staining was not detected in normal lungs. Passive immunization with anti-MCP-1 antibodies caused a 40% reduction in the secondary granuloma area but did not significantly affect the primary response. With adoptive cell transfer and T cell subset depletion, it was shown that Thy-1+ and CD5+ cells augmented, whereas CD8+ cells appeared to impair, MCP production. This provides direct evidence that MCP is involved in secondary Th2-mediated response to schistosome eggs and is subject to regulation by T cells.     

Role of basal insulin in the regulation of protein kinetics and energy metabolism in septic patients.

We have investigated the role of basal insulin concentration on leucine kinetics (determined by means of 1-[13C]leucine) and energy metabolism (determined by indirect calorimetry) in eight septic patients by reducing insulin (and glucagon) secretion by somatostatin infusion. Basal glucagon concentration was elevated (744 +/- 381 pg/mL), and insulin concentration was normal (10 +/- 4 microU/mL). Basal resting energy expenditure (REE) was 151 +/- 8% that of predicted basal energy expenditure, and leucine appearance (Ra), oxidation, and nonoxidative disposal rates were all elevated above the normal ranges. Somatostatin infusion reduced insulin concentration by 52% and glucagon concentration by 64%. This resulted in a significant increase in the rate of leucine oxidation from 0.96 +/- 0.08 to 1.18 +/- 0.14 mumol/kg/min (p less than 0.01), and nonoxidative leucine disposal decreased from 2.95 +/- 0.18 to 2.67 +/- 0.17 mumol/kg/min (p less than 0.01). Somatostatin infusion also caused significant increases in REE and fat oxidation from 1310 +/- 100 to 1505 +/- 128 kcal/m2/day (p less than 0.05) and from 1.72 +/- 0.24 to 2.41 +/- 0.41 mg/kg/min, respectively, and a slight decrease of carbohydrate oxidation from 1.51 +/- 0.49 to 1.31 +/- 0.49 mg/kg/min. These metabolic responses can be attributed to the reduction in insulin concentration, because they are in the opposite direction of changes that would occur as a consequence of a reduction in glucagon concentration. We conclude that the basal insulin plays an important role in attenuating net protein loss and energy expenditure.     

Acquired circulating anticoagulants.

Acquired inhibitors of blood coagulation, which are pathologic circulating substances that directly inhibit clotting factors or their reactions, most commonly occur in patients with hereditary bleeding disorders. This article contains a discussion of acquired circulating anticoagulants that arise de novo in patients with previously normal hemostatic mechanisms. Pathogenesis and management are also discussed. Treatment of these patients poses a challenge for the hematologist because, unlike hereditary hemophiliacs who have learned to adjust their lifestyle, the acquired hemophiliac is unprepared for hemorrhagic episodes.     

Infection of the upper extremity byMycobacterium marinum in a 3-year-old boy — Diagnosis by 16S-rDNA analysis

Summary A 3-year-old boy developed several subcutaneous nodular lesions on his right arm. Based on the histological examination of one of these nodules furunculosis was suspected and cefuroxime was tentatively given. However, acid-fast bacilli were then detected in the tissue specimen and a few colonies of acid fast, gram-positive rods grew on blood agar. Definitive species diagnosis (Mycobacterium marinum) was rapidly achieved by automated sequencing of amplified 16S-rDNA and antimicrobial therapy was adjusted according to the available literature. After 3 weeks of treatment with clarithromycin, rifampicin and protionamid regression of the nodular lesions was evident.

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Infektion der oberen Extremität durchMycobacterium marinum — Diagnose mit Hilfe von 16S-rDNA Analyse

Zusammenfassung Wir berichten von einem 3-jährigen Jungen, der verschiedene subkutane Knoten im rechten Arm entwickelte. Nach histologischer Untersuchung wurde zunächst der Verdacht auf Furunkulose geäußert und eine vorläufige Therapie mit Cefuroxim begonnen. Es wurden dann jedoch säurefeste Stäbchen im entnommenen Gewebe nachgewiesen und eine Woche später auf Blutagar grampositive, säurefeste Stäbchen angezüchtet. Die definitive Speziesdiagnose (Mycobacterium marinum) wurde rasch mit automatischer 16S-rDNA Sequenzbestimmung erzielt und die Therapie entsprechend der verfügbaren Literatur korrigiert. Nach drei Wochen einer Behandlung mit Clarithromycin, Rifampicin und Protionamid war ein Rückgang der subkutanen Knoten erkennbar.

     

Comparison of chemical, histomorphometric, and absorptiometric analyses of bones of growing rats subjected to dietary calcium stress

Absorptiometric, histomorphometric, and chemical analyses of bones from growing rats fed diets with low (0.2%, w/w), marginal (0.4%, w/w), or adequate (0.8%, w/w) calcium (Ca) content with or without phytate were compared. Phytate was added to each diet in a molar ratio of 19:1 to calcium. Male weanling Sprague-Dawley rats were fed one of the six diets for 8 weeks. At the end of 8 weeks, rats were killed, and mandibles, femurs, and tibias were removed. Bone density profiles were determined on the mandibles and femurs using single photon absorptiometry. Femurs were also used for calcium and phosphorus analyses. Tibias were used for histomorphometric analyses. Bone density of the femurs and mandibles increased as dietary Ca increased. The only effect of phytate addition measured was in the 0.8% calcium diet, where density was lower in rats fed the phytate-containing 0.8% calcium diet. Femur calcium concentration also increased as dietary Ca increased and was unaffected by addition of phytate. Femur phosphorus concentration was unaffected by dietary Ca levels but was increased by 10% when phytate was added to the diet. Bone density values were highly correlated with bone calcium and phosphorus levels (r = 0.94). Rats fed the 0.2% calcium diets had 20% lower mineralized bone area and 20% larger medullary cavity area than rats fed the other diets. Bone densitometry appears to be useful for determining changes in bone occurring in growing rats fed low, marginal, and adequate levels of dietary Ca. Bone density values also correlated well with chemically determined calcium and phosphorus concentrations and with histomorphometric data.     

The role of dialysate in the stimulation of interleukin-1 production during clinical hemodialysis

To evaluate the role of the dialysate in the stimulation of interleukin-1 (IL-1) production during clinical hemodialysis (HD), we studied maintenance HD patients in two experiments. Cellulosic hollow-fiber dialyzers were obtained after 20 minutes of HD using either nonsterile standard dialysate (n = 6) or sterile pyrogen free 0.9% saline as dialysate (n = 6). After rinsing the blood compartment with normal saline, dialyzers were incubated at 37 degrees C for six hours. Aliquots from the blood compartment were analyzed for the presence of IL-1 by (1) rabbit pyrogenic response after intravenous injection or (2) thymocyte co-proliferation assay. The in vivo assay showed a significantly greater febrile response when standard dialysate was used than in the sterile saline group (P less than .001), and this response could be abolished by heat inactivation of aliquots (P less than .001). The in vitro assay confirmed the presence of significantly greater amounts of IL-1 (P less than .05). Studies were repeated using filter sterilized standard dialysate (n = 6) v standard dialysate (n = 6) for 240 minutes of clinical HD. The in vitro assay revealed significantly lower IL-1 levels in the filtered sterilized dialysate group (P less than .05), however, a blank control assay showed yet significantly lower levels (P less than .05). We conclude that IL-1 is produced during clinical HD and that endotoxin or its fragments play a role in the stimulation of IL-1 production, probably through monocytes adhering to the dialysis membrane. In addition to this dialysate factor, IL-1 production appears also to be stimulated by a blood-membrane interaction.