Manifestations of tick-borne illness. Incidence and variety are increasing worldwide.

The incidence and variety of diseases associated with tick bites have continued to grow worldwide. Lyme disease, the most common tick-borne disease in the United States, has received extensive media coverage because of its protean manifestations and propensity for causing chronic disease. Our ability to prevent, identify, and effectively treat Lyme disease and other tick-borne diseases has significantly improved in the last decade. Tick-borne illnesses should be one of the differential diagnostic considerations in patients with consistent clinical findings and exposure history. In addition, the prudent use of laboratory testing ensures an accurate diagnosis while avoiding the cost and risk of inappropriate diagnostic tests and antibiotic therapy.

Ferrous sulfate-induced increase in requirement for thyroxine in a patient with primary hypothyroidism.

Recent studies have shown that under experimental conditions ferrous sulfate may reduce the gastrointestinal absorption of orally administered levothyroxine sodium in patients with primary hypothyroidism. We describe a patient who became hypothyroid while taking ferrous sulfate. The hypothyroid status was corrected by increasing the dose of levothyroxine. Subsequently, when ferrous sulfate was discontinued, the patient became hyperthyroid while taking the higher dose of thyroid hormone preparation. Since both hypothyroidism and iron deficiency anemia may coexist, additional thyroid function testing is recommended in patients treated concurrently with ferrous sulfate and L-thyroxine.

When is couples therapy necessary and sufficient?

Couples therapy is not a unified form of treatment but draws on a heterogeneous range of influencing processes. When distressed couples are relatively stable and interested in effecting a harmonious modus vivendi, didactic training will usually achieve salubrious outcomes. When individual agendas, hidden or otherwise, undermine the relationship, individual therapy is often essential before the couple can benefit from conjoint therapy. Those who insist on working only within dyadic, triadic, or family contexts may fail to achieve desirable goals.

The multimodal approach to the treatment of minor depression.

The multimodal approach endeavors to achieve rapid remission of depressive symptoms and significant relapse prevention. It is predicated on the assumption that it is usually insufficient to facilitate the acquisition of insight, dispute irrational ideas, and change negative automatic thoughts. In addition to the foregoing, behavioral deficits, sensory overloads, and negative imagery must be identified and remedied, and antidepressant medication should be considered. This paper outlines a seven-pronged approach in the treatment of "minor" depression. Some of the procedures include: assertiveness training, a "sensate focus" of enjoyable events, coping imagery, time projection, cognitive disputation, role-playing, desensitization, family therapy, and biological prophylaxis. In essence, this broad-based approach recommends that attention be paid not only to cognitive issues, but also to specific behaviors, sensations, images, interpersonal relationships, and other interactive effects. The multimodal framework (BASIC I.D.) enables the practitioner to administer the necessary measures in a systematic and comprehensive manner.

Pulmonary manifestations of leptospirosis.

Pulmonary involvement in leptospiral infection is common, usually mild, and often overlooked. When pulmonary manifestations are prominent in a patient with leptospirosis, there is the potential for diagnostic confusion. We present the case of a patient with adult respiratory distress syndrome secondary to leptospirosis and review the pulmonary manifestations of leptospiral infection.

Hemoptysis. Indications for bronchoscopy.

Indications for bronchoscopy in patients with hemoptysis and a normal or nonlocalizing chest roentgenogram continue to be controversial. We reviewed the records for 119 bronchoscopies performed for hemoptysis in patients with a normal (n = 75) or nonlocalizing (n = 44) chest roentgenogram. Bronchogenic carcinoma was identified in 2.5% of the bronchoscopies. Additional neoplasms were found in another 2.5%. The presence of nonlocalizing abnormalities was not associated with an increase in either the rate of bronchogenic carcinoma or in the diagnostic yield (specific anatomic diagnosis or bleeding site identified) at bronchoscopy when compared with patients with normal chest roentgenograms. The factors of male sex, age more than 40 years, and a more than 40 pack-year smoking history appear useful in identifying patients in whom the yield of bronchoscopy is likely to be high.

Can psychotherapists transcend the shackles of their training and superstitions?

Formal courses and training in psychological diagnosis and treatment often undermine the talents and skills with which many trainees are endowed naturally. Too many seem to acquire a stylized professionalism replete with general labels, questionable theories, and unfortunate proscriptions. Despite lip service paid to prescriptive eclecticism, most graduate programs socialize their students into delimited schools of thought. Meanwhile, hundreds of psychotherapeutic systems have proliferated. Unsubstantiated claims abound. Nevertheless, there are data that show that specific treatments of choice exist for many disorders. It is argued that a multimodal, systematic, technically eclectic model can point the way to a genuinely scientific approach to psychotherapy.

Sarcoidosis diagnosed in a patient with known HIV infection.

A 29-year-old black man with HIV infection had an abnormal chest x-ray film with bilateral hilar adenopathy. Sarcoidosis was suspected, but a thorough and comprehensive evaluation was completed to differentiate the multiple infectious and noninfectious causes of these findings. Biopsy of a hilar node and pulmonary tissue revealed sarcoidosis.

Lymphoid interstitial pneumonia: clinicopathological and immunopathological findings in 18 cases.

Eighteen patients with lymphoid interstitial pneumonia (LIP) were studied. The diagnosis was established by the microscopic finding of interstitial infiltrates of lymphocytes and plasma cells. Forty-seven% of patients also had germinal centres, while 72% showed interstitial giant cells. Cases studied by the immunoperoxidase technique showed the interstitial plasma cells to be polytypic. The median age of patients was 56 years; most had cough, dyspnea, or chest pain. Chest X-rays showed either patchy interstitial infiltrates (usually bilateral) or poorly defined nodules. Ten patients had hypergammaglobulinemia; one had hypogammaglobulinemia. Two patients had Sjögren's syndrome, two had biopsy-proven chronic active hepatitis, and two had a clinical diagnosis of primary biliary cirrhosis. Follow-up examination of 14 patients showed clearing of symptoms, X-ray infiltrates or stable infiltrates in 4 cases each. Five patients died (mean survival, 41 months), one of whom succumbed to disseminated lymphoma and a second to respiratory failure. Our results support the hypothesis that LIP is a non-neoplastic cellular proliferation in which lymphoma may supervene. The high incidence (22%) of chronic liver disease has not previously been noted.

Pulmonary involvement in Sweet's syndrome (acute febrile neutrophilic dermatosis). Preleukemic and leukemic phases of acute myelogenous leukemia.

A 60-year-old man developed histologic lesions characteristic of acute febrile neutrophilic dermatosis in skin and lung during preleukemic and leukemic phases of acute myeloid leukemia. These lesions showed improvement and resolution during oral prednisone therapy, requiring higher doses during each relapse. The response to prednisone therapy was enhanced by concomitant administration of effective antileukemic chemotherapy.

Lymphomatoid granulomatosis: a clinicopathologic study of 42 patients.

We studied the histological and clinicopathological findings in 42 patients who had lymphomatoid granulomatosis (LYG). In addition to small round lymphocytes, small to intermediate lymphocytes with serpentine nuclei, large immature mononuclear lymphoid cells, abundant histiocytes, and vascular invasion by the cell infiltrate were observed in all cases. Fifty percent of lesions had occasional "atypical" cells with multi-lobed nuclei. Three of four follow-up autopsies showed large cell lymphoma, while one other autopsy and the single repeat biopsy showed increased numbers of large immature mononuclear lymphoid cells. Patients were most frequently men 40-60 yr old who had a history of pulmonary symptoms, such as cough or chest pain, and who showed multiple bilateral lung nodules without hilar adenopathy in the chest x-ray. Thirteen patients (38%) died of disease, 11 of them within 12 mth of initial diagnosis. The presence of neurological signs and symptoms, increased mitoses, or increased numbers of atypical multi-nucleated cells in the initial biopsy were not statistically significant predictors of survival.

Primary non-Hodgkin's lymphoma and pseudolymphoma of lung: a study of 161 patients.

The authors studied 161 cases of primary non-Hodgkin's lymphomas and pseudolymphomas of lung. Small lymphocytic proliferations, which they believe to be lymphomas, constituted 31.6 per cent of cases; plasmacytoid lymphocytic and small cleaved follicular center cell lymphomas (Lukes-Collins system), 22.4 and 11.8 per cent of cases, respectively; and the remaining follicular center cell lymphomas and B-immunoblastic sarcomas, 5.6 per cent of cases. Pseudolymphomas constituted 14 per cent of cases. Most patients were elderly and asymptomatic; in most cases a solitary nodule or infiltrate was observed on a chest radiograph. Radiographic evidence of effusion was found in both lymphomas and pseudolymphomas, but hilar adenopathy was restricted to lymphomas. A few peribronchial reactive germinal centers and intralesional giant cells/granulomas were seen frequently in unequivocal lymphomas, so their presence cannot be used to exclude neoplasia. A generally monomorphic cell population and invasion of bronchial cartilage or visceral pleura are suggestive of malignancy, whereas primitive cytologic appearance and invasion of lymph nodes or parietal pleura are pathognomonic of malignancy. Diffusely admixed mature lymphocytes and plasma cells with numerous reactive follicles suggest pseudolymphomas. Immunologic determination of clonality may be diagnostically definitive. Most localized lesions in lung were treated by surgical resection, whereas in cases of extensive pulmonary disease, biopsies were performed and patients were treated by chemotherapy or irradiation. Both lymphomas and pseudolymphomas recurred, most often within three years. Pseudolymphoma recurred only in lung. When distant spread of lymphoma occurred, it commonly involved extranodal sites. Only 18 of 101 patients with lymphoma died with or of tumor, and no patient with pseudolymphoma died of disease. Neither histologic subtype among the "small cell" lymphoid lymphomas nor the presence of regional node involvement was prognostically significant, but pleural effusion on the initial chest radiograph was a significant predictor of both recurrence and mortality.

Sarcoidosis.

According to the Subcommittee on Classification and Definition of Sarcoidosis, it is a multisystem granulomatous disorder of unknown etiology. It most commonly affects young adults and presents most frequently with bilateral hilar adenopathy, pulmonary infiltrates, and skin or eye lesions. The diagnosis is established when clinical findings and appropriate x-ray findings are supported by tissue biopsy specimens in which noncaseating epithelioid cell granulomas are found. Immunologic features of the disease include depression of delayed hypersensitivity reactions, suggestive of impaired cell mediated immunity, and increased or abnormal immunoglobulin levels. Hypercalciuria may occur, with or without hypercalcemia. The course and prognosis of the disease correlate with the mode of onset. An acute onset in the presence of erythema nodosum indicates a self-limited course with spontaneous resolution, whereas an insidious onset may be followed by a relentless course. Corticosteroids are useful when therapy is required, as well as to suppress inflammation and the occurrence of granulomatous changes.