A cloudy bag and genital ulcers.

A 30-year-old patient treated with CCPD presented with genital ulcers and a culture-negative peritonitis. Herpes simplex virus type 2 (HSV-2) was cultured from the effluent and the genital lesions. Primary HSV-2 infection was diagnosed by serology. This is the first documented case of PD peritonitis caused by HSV-2. We speculate that cases of culture-negative PD peritonitis may be due to recurrences of genital herpes.

A young woman with fever and a pericardial effusion.

A 19-year-old woman is presented with high-spiking fever, pericardial tamponade and respiratory failure. A diagnosis of adult onset Still's disease was made. This is a rare inflammatory disease with an unknown aetiology. The diagnosis is made by exclusion and with the help of diagnostic criteria. Treatment with corticosteroids met with a good response.

Beer drinker's hyponatraemia: a case report.

Beer drinker's hyponatraemia, also called beer potomania, is a syndrome of hyponatraemia in patients who consume excessive amounts of beer and have a poor dietary intake. We describe a patient with chronic asymptomatic hyponatraemia due to beer potomania. The pathophysiology of this syndrome, the treatment and prevention are reviewed.

Splenic epithelial cysts and splenomegaly: diagnosis and management.

Splenomegaly is a common problem. In the absence of systemic illness or malignancy splenic cysts must be considered, especially the epithelial variety. For large cysts total splenectomy has long been recommended. Recognition of the risk of an overwhelming postsplenectomy infection (OPSI), especially in children, has led to spleen conserving surgery. We describe the use of an absorbable Vicryl net after partial splenectomy with total cystectomy in the management of splenic epithelial cysts.

[Mannitol poisoning: anuria caused by a diuretic]. / Mannitolintoxicatie: anurie door een diureticum.

In a 75-year-old man treated for cerebral oedema with mannitol, anuria developed after two days' treatment. Within a few hours after haemodialysis renal function returned. High doses of mannitol can cause acute renal failure, especially in patients with pre-existing renal impairment. Lowering of the concentration of mannitol in plasma by haemodialysis will rapidly restore renal function.

[Anuria and recurrent pulmonary edema due to ischemic nephropathy successfully treated with surgical renal revascularization]. / Anurie en recidiverend longoedeem door ischemische nefropathie succesvol behandeld door chirurgische renale revascularisatie.

In a 61-year-old man, who had undergone left-sided nephrectomy in the past, and who came with anuria and recurrent pulmonary oedema, complete obstruction of the right renal artery was diagnosed. Recurrent pulmonary oedema may be a manifestation of ischaemic renal disease. This clinical entity is not rare and may lead to terminal renal insufficiency. Both surgery and angioplasty can preserve or improve renal function and make dialysis therapy unnecessary. In the patient described, the stenotic part of the renal artery was resected and the vessel connected to the aorta end to side; the patient recovered.

Deficiency of complement component C3 is associated with accelerated removal of soluble 123I-labelled aggregates of IgG from the circulation.

Complement and erythrocyte complement receptors CR1 (CD35) play an important role in the clearance of immune complexes. We studied the elimination of soluble 123I-labelled aggregates of human immunoglobulin G (123I-AIgG), used as a model for immune complexes, in two patients with a congenital and two patients with an acquired deficiency of complement component C3, and compared these with 10 healthy controls. The first disappearance halflife of 123I-AIgG was shorter (3.3 +/- 0.4 versus 7.0 +/- 0.4 min in the controls, P = 0.005) and maximal hepatic uptake of aggregates was increased in the C3 deficient patients (maximal liver/background ratio 3.6 +/- 0.4 versus 2.7 +/- 0.2 in controls, P = 0.04). Apparently, in the absence of C3, removal of circulating immune complexes by the liver is accelerated, probably through Fc receptor-dependent mechanisms.

In vivo clearance by the mononuclear phagocyte system in humans: an overview of methods and their interpretation.

The mononuclear phagocyte system (MPS) is responsible for the elimination of foreign material, effete autologous material and immune complexes. To study the relationship between MPS function and human disease, several test substances have been developed, and used to determine the clearance capacity of the MPS in human subjects in vivo. These test substances and the multitude of factors that influence the elimination of these substances (and complicate the interpretation of the test results) are discussed. Use of these probes has provided important new insights, that may lead to the development of treatment modalities by which MPS function is modified in order to influence disease processes more effectively.

Antibodies against C1q in anti-glomerular basement membrane nephritis.

The prevalence of antibodies against the collagen-like region of the subcomponent of the first component of complement, C1q, was investigated in 11 patients with anti-glomerular basement membrane (GBM) nephritis. Anti-C1q antibodies (anti-C1qAb) were detected in seven patients. IgG anti-C1qAb were found in four and IgA anti-C1qAb in five patients. During follow up of the patients a relationship was observed between the levels of IgG anti-C1qAb and the levels of anti-GBM antibodies (anti-GBMAb). Gelfiltration experiments indicated that both IgG anti-C1qAb as well as IgG anti-GBMAb were monomeric and that binding also occurred with the F(ab')2 fragments of the antibodies. Although anti-C1qAb and anti-GBMAb are both directed against a collagen-like structure, it was demonstrated by means of inhibition experiments that anti-C1qAb and anti-GBMAb are directed against different antigenic sites. Comparison of patients with anti-GBM nephritis with and without anti-C1qAb revealed that there were no differences in disease activity or disease severity. Therefore, the results of this study suggest that anti-C1qAb do not play a direct pathogenetic role in anti-GBM nephritis.

Does haemodialysis impair macrophage Fc receptor function?

Patients treated with chronic haemodialysis are at risk of infections, possibly because of impaired function of macrophage Fc receptors. Using [123I]-labelled aggregates of human IgG ([123I]-AIgG) as a probe of Fc-receptor-mediated function, we examined eight patients treated with chronic intermittent haemodialysis (HD), eight patients treated with CAPD, eight patients with preterminal renal failure who had not yet received renal replacement therapy, and eight healthy controls. In all three patient groups the first elimination half-life of [123I]-AIgG was decreased, suggesting accelerated binding of the probe. In the HD group overall clearance of [123I]-AIgG was similar to the value found in healthy controls. In the CAPD and preterminal renal failure group clearance was decreased as compared with the HD patients. Uptake of [123I]-AIgG by liver and spleen was quantitatively similar in patients and controls, but hepatic uptake of [123I]-AIgG reached its maximum earlier in the patients treated with HD. These results suggest that Fc receptor function is not impaired in patients who undergo chronic haemodialysis.

IgG and IgA autoantibodies to C1q in systemic and renal diseases.

Antibodies to the collagen-like region of C1q have been described in patients with SLE and rheumatoid vasculitis. In this study the prevalence of both IgG and IgA C1qAb was assessed in serum samples of 385 patients with different systemic and renal diseases. The results demonstrate that the prevalence of IgG and IgA C1qAb is not restricted to the diseases in which they were originally described. C1qAb can also be demonstrated in patients with MCTD, Felty's syndrome, ankylosing spondylitis, polyarteritis nodosa, mixed cryoglobulinaemia, membranoproliferative glomerulonephritis, glomerulosclerosis, and patients with anti-glomerular basement membrane nephritis. The widespread occurrence of C1qAb of both immunoglobulin classes in systemic and renal diseases may provide insight into the mechanisms that lead to C1qAb formation.

A five day course of high dose corticosteroids has no effect on the clearance of soluble aggregates of human immunoglobulin G in healthy volunteers.

It is thought that glucocorticosteroids impair the clearance of immune complexes by the mononuclear phagocyte system (MPS). We studied the effect of a five day course of prednisone (1 mg/kg body weight per day) on MPS function in 10 healthy volunteers, using soluble radiolabeled aggregates of human immunoglobulin G as a probe. MPS function was assessed before steroid treatment, and again 24 hours after the last dose of prednisone. Elimination kinetics and the uptake of the immunoglobulin aggregates by liver and spleen did not change after prednisone treatment. This suggests that, in contrast to general belief, high doses of glucocorticosteroids have no direct, acute effect on MPS function.

Effect of monomeric immunoglobulin G (IgG) on the clearance of soluble aggregates of IgG in man.

Serum concentrations of IgG may influence Fc receptor-mediated clearance of immune complexes. For instance, when 123I-labeled aggregates of human IgG (123I-AIgG), used as a model for soluble immune complexes, are administered to patients with systemic lupus erythematosus (SLE), there is an inverse correlation between the serum concentrations of IgG and the clearance and volume of distribution in steady state (Vss) of 123I-AIgG. To answer the question whether IgG has a direct effect on the clearance of immune complexes, we measured the elimination of 123I-AIgG in eight patients with hypogammaglobulinemia, before and after substitution with intravenous gammaglobulin (IVIG). As expected, raising IgG concentrations in these patients (by 6 g/l) caused a significant decrease of the Vss of 123I-AIgG. However, clearance of 123I-AIgG remained unchanged by IVIG. Thus, the results of this study offer no experimental evidence that raising concentrations of IgG influences the clearance of soluble immune complexes.