Giant splenomegaly and refractory hypercalcemia due to extrapulmonary sarcoidosis. Successful treatment by splenectomy.

Sarcoidosis is a granulomatous disease of unknown origin with a variable clinical presentation. The presenting complaint is usually referable to the lung. We describe an unusual presentation of sarcoidosis in a young black man who received medical attention for evaluation of pancytopenia, giant splenomegaly, and marked, refractory hypercalcemia. After extensive evaluation, including exploratory laparotomy, he was found to have sarcoidosis, with extensive involvement of his spleen, liver, and abdominal lymph nodes. Pulmonary involvement was notably absent, with no suggestive findings radiographically on gallium citrate Ga 67 scanning or on bronchoscopy with transbronchial biopsy. This patient underwent splenectomy and, following removal of the massive splenic granuloma burden, the hypercalcemia resolved completely with no other therapy.

Delayed treatment with an LTD4/E4 antagonist limits pulmonary edema in endotoxic pigs.

We used a selective leukotriene (LT) D4/E4 receptor antagonist (LY 203647) to investigate the role of cysteinyl LTs as mediators of several important pathophysiological events in a porcine model of endotoxic shock. Pentobarbital-anesthetized pigs (11.8-17.5 kg) were mechanically ventilated with 100% O2. Pigs in groups I (n = 10), IIA (n = 10), and IIB (n = 5) were infused with Escherichia coli lipopolysaccharide (LPS; 250 micrograms/kg) from time (t) = 0-20 min. Pigs in group III (n = 3) were normal controls. All pigs were resuscitated from t = 0-240 min with Ringer lactate (0.8 ml.kg-1.min-1). Pigs in group I received no further treatment. At t = 30 min, groups IIA and IIB were injected with LY 203647 (30 mg/kg) and were started on an infusion of the compound at 10 (group IIA) or 30 mg.kg-1.h-1 (group IIB). Delayed treatment with LY 203647 significantly (P less than 0.05) and persistently ameliorated LPS-induced pulmonary hypertension. The compound also abrogated LPS-induced pulmonary edema, as assessed by gravimetrically determined lung extravascular wet-to-dry weight ratios. Despite its beneficial effect on pulmonary edema, delayed treatment with LY 203647 did not improve arterial oxygenation. Delayed treatment with LY 203647 transiently improved mesenteric perfusion. These data suggest that cysteinyl LTs are important mediators in porcine endotoxicosis.

Leukotriene C4 induces mesenteric hypoperfusion and intestinal intramural acidosis in pigs.

We examined the effect of intravenous infusion of graded doses of authentic leukotriene (LT) C4 on several physiological variables in pentobarbital-anesthetized immature swine. Mesenteric blood flow (Qsma) was measured using an ultrasonic flow probe and ileal intramucosal hydrogen ion concentration ([H+]I) was estimated tonometrically. Three groups were studied. Pigs in Group I (n = 6) were infused beginning at t = 0 min with increasing doses (0.03-1.0 microgram/kg-min) of LTC4, each dose being administered for 10 min. Pigs in Group II (n = 6) were infused with LTC4 as above, but were pre- and post-treated with a specific sulfidopeptide LT receptor antagonist, LY203647 (30 mg/kg bolus and then 10 mg/kg-hr) beginning at t = -20 min. Pigs in Group III (n = 4) received only normal saline (5 ml/kg-h). Infusing LTC4 significantly decreased Qsma and mesenteric oxygen uptake and significantly increased ileal [H+]I. These changes were prevented by LY203647. These data support the idea that sulfido-peptide LT are capable of causing mesenteric ischemia and that this phenomenon can be blocked by LY203647.

Beneficial effects of LY203647, a novel leukotriene C4/D4 antagonist, on pulmonary function and mesenteric perfusion in a porcine model of endotoxic shock and ARDS.

The sulfidopeptide leukotrienes (LT) have been implicated as important pathophysiological mediators in septic shock. To further define the role of these compounds, we utilized a porcine endotoxicosis model to study the effects of pre- and concurrent treatment with LY203647, a novel LT receptor antagonist. Pentobarbital-anesthetized pigs (13-20 kg) were mechanically ventilated with 100% O2. Superior mesenteric arterial flow (Qsma) was measured using an ultrasonic flow probe. Ileal intramucosal hydrogen ion concentration, [H+]1, was estimated tonometrically. Pigs in groups I and II were infused with endotoxin (250 micrograms/kg) and resuscitated with saline (1.2 ml/kg min). Group I (n = 8) were controls; Group II (n = 8) were pretreated with LY203647 (30 mg/kg bolus, then 10 mg/kg h). Treatment with LY203647 persistently and significantly (P less than .05) improved post-LPS pO2 and transiently improved Qsma. Treatment with LY203647 did not affect [H+]1. Lung extravascular wet-to-dry weight ratios were 7.13 +/- .33 and 5.43 +/- .09 in groups I and II, respectively (P less than .001). These data suggest that sulfidopeptide LT are important mediators of key pathophysiologic events in this porcine model of endotoxic shock and the adult respiratory distress syndrome (ARDS).

Validation of tonometric measurement of gut intramural pH during endotoxemia and mesenteric occlusion in pigs.

Tonometry is a minimally invasive method for estimating gastrointestinal intramural pH (pHi). Tissue pH is calculated by using the Henderson-Hasselbalch equation and measurements of arterial [HCO-3] and CO2 tension (PCO3) of saline contained in a Silastic balloon within the lumen of the gut. The validity of the method rests on two key assumptions: 1) PCO2 in saline in the tonometer balloon is similar to tissue PCO2 and 2) tissue and arterial [HCO-3] are similar. To validate this method, ileal pHi measured directly with a microelectrode was compared with pHi estimated tonometrically in four groups of anesthetized pigs. Group I (n = 4) were controls. In group II (n = 4), intestinal tissue acidosis was induced by total occlusion of the superior mesenteric artery (SMA). In group III (n = 5), acidosis was induced by partial occlusion of the SMA. In group IV (n = 4), tissue acidosis was induced by endotoxemia. Agreement was excellent between direct and tonometric measurements in groups I and IV and less good in groups II and III. Weighted mean correlation coefficients (rw) for the two measurement methods were 0.743 and 0.9447 in groups II and IV, respectively. Correlation coefficients for the individual animals in group III were more variable than the other groups and ranged from 0.547 to 0.990. The tonometric method for measuring GI pHi is invalid under conditions of zero flow and leads to error under conditions of low flow. However, the method is reliable in the setting of tissue acidosis induced by endotoxemia.