[Toxic damage of kidney, liver and muscle attributed to the administration of germanium-lactate-citrate]. / Toxische beschadiging van nier, lever en spier toegeschreven aan het gebruik van germanium-lactaat-citraat.

The case history is described of a woman aged 57 years with renal, hepatic and muscular damage attributed to intake of germanium lactate-citrate (a cumulative dose of 32.1 g germanium) over at least one year, as alternative treatment of metastatic breast cancer. Histological examination of biopsies showed highly vacuolated cytoplasm of the epithelial cells of the distal renal tubules and micro- and macrovesicular steatosis of centrilobular hepatocytes. After discontinuation of the germanium, serum aminotransferases and creatine kinase values returned to normal, but moderately severe renal impairment persisted.

Successful treatment of a patient with retractile mesenteritis with prednisone and azathioprine.

A patient with retractile mesenteritis is discussed, who presented with a huge 15 X 15-cm inflammatory mass involving the root of the mesentery. Gradually the patient developed duodenal obstruction for which it was necessary to perform a gastroileostomy. Because of a relentless downhill course with fever, weight loss, general malaise, and fatigue, it was finally decided to treat the patient with prednisone and azathioprine. Upon institution of this treatment there was a steady, progressive clinical amelioration with disappearance of fever, improvement in laboratory findings, and gradual regression of the lesion until it became a well-delineated hard mass that was thought to be the end stage of fibrosis. Early trial with such a treatment, once the diagnosis is firmly established, should be considered.

Radionuclide fetal imaging: radio-activity in the fetal bladder confirmed by ultrasound after maternal hepato-biliary scanning.

Hepato-biliary scanning with 99mTc-P.G. demonstrated in a jaundiced patient at 31 weeks pregnancy the filling of the fetal bladder 6 h after injection. This finding was confirmed by ultrasound. Fetal urinary bladder activity was seen until 33 h after injection. Fetal hepatic radio-activity could not be displayed although the localisation of the fetal liver was marked by ultrasound.

Hepatobiliary scanning with 99mTc-pyridoxylidene glutamate. A retrospective study investigating the criteria for differentiation between intrahepatic and extrahepatic obstruction.

In 70 99mTc-pyridoxylidene glutamate (PG) studies with verified diagnoses, the following scan patterns were found. (1) Normal: within 30 min of PG injection the scan reveals the liver, hepatic ducts, common bile duct, gallbladder and flow to the intestine; after 2 h the liver had a higher concentration of activity than the hepatic ducts or the common bile duct. (2) Complete extrahepatic obstruction: no hepatic excretion to the intestine is observed 18-24 h after PG injection, nor is activity observed in the hepatic ducts, common bile duct and gallbladder. (3) Incomplete extrahepatic obstruction: intestinal activity is observed within 18-24 h of PG injection; after 2 h the concentration of activity in the hepatic ducts or the common bile duct exceeds that in the liver (regardless whether activity is or is not demonstrated in the gallbladder). (4) No extrahepatic obstruction: serum bilirubin normal or increased; intestinal activity is observed within 18-24 h after PG injection, and activity is demonstrable during this period somewhere in the hepatic ducts, the common bile duct or the gallbladder; after 2 h the concentration of biliary activity should not exceed that in the liver. (5) If excretion to the intestine is observed within 18-24 h of PG injection without demonstrable activity in the hepatic ducts, common bile duct or gallbladder, then it is impossible to differentiate between (3) and (4).

Sensitivity of ultrasound in the detection of biliary tract obstruction.

In 28 patient with varying degrees of biliary obstruction, the ultrasonic findings were correlated with the serum bilirubin levels and with the size of the bile ducts as measured by percutaneous transhepatic cholangiography (PTC). With ultrasound, study of the intrahepatic ducts achieved the greatest accuracy (71%); examination of common bile ducts and the gallbladder were found to be less sensitive (54 and 53%). Ultrasound proved to be very accurate in biliary obstruction, when the serum bilirubin was above 4.8 mg/100 ml (80 mumol/1).

Acute-phase proteins from the liver and enzymes from myocardial infarction; a quantitative relationship.

In 14 patients with acute myocardial infarction (M.I.) not having any other disease, the possible quantitative relationship between enzymes from M.I. and changes in concentration of acute phase reactants coming from the liver were studied. The patients were followed up until 1 1/2 years after M.I. and comparison of baseline-protein values took place using a control group of 18 healthy individuals. Quantitation of protein changes was done by planimetric determination of the area under the concentration curve and by taking peak values. The myocardial infarction was quantitatively estimated by mathematical analysis of the time course of alpha-hydroxybutyrate dehydrogenase (alpha-HBDH) plasma concentrations and by taking peak values. A quantitative relationship with enzymatic infarct size was found for haptoglobin, alpha1-acid glycoprotein, alpha1-antitrypsin, C-reactive protein, fibrinogen and E.S.R. Albumin and transferrin did not show a negative quantitative relationship with enzymatic infarct size. Humoral factors originating from the site of tissue injury and evoking in proportion a positive acute phase reaction by the liver are probably the basis for this observed quantitative relationship.

Vitamin B12 and bile acid metabolism in patients with partial iieal resection.

The vitamin B12 and bile acid metabolism was studied in 20 patients in whom a standardized Bricker procedure without irradiation was performed. No significant vitamin B12 malabsorption, steatorrhea, fecal bile acid loss or bile acid deconjugation was found. Therefore, no long-term adverse metabolic consequences of segmental preterminal ileal resection are to be expected in these patients.

Liver reaction to tissue injury: do therapeutic measures trigger the acute phase reaction?

In 30 healthy people we investigated the hypothesis that therapeutic measures trigger the acute phase reaction. In order of severity we analyzed: (1) the effects of an intramuscular injection of 2.5 ml 0.14 molar NaCl (6 patients), (2) the effects of an indwelling venous catheter for 24 h (7 patients), and for 72 h (8 patients), (3) the effects of cardiac catheterization (arterial and venous catheterization) carried out in 9 patients. In clinical investigations of the acute phase reaction, an intramuscular injection and a 24- or 72-h indwelling catheter, brought in by venipuncture, are acceptable because they do not provoke an acute phase reaction. A venous cutdown associated with an arterial puncture is not acceptable because this injury evokes a positive acute phase reaction. This was also observed in two patients who developed phlebitis during a 24-h indwelling venous catheter. Only a positive acute phase reaction was found, not a negative one.