Intradermal hepatitis B vaccination in a 300-bed primary care hospital: experience with a recombinant vaccine in a four-dose schedule.

BACKGROUND: All hepatitis B vaccination programs, regardless of route, must address such factors as primary response rate, additional booster injections for primary nonresponders, antibody persistence, the need for and timing of additional booster injections for primary responders, overall costs, and medical efficacy. A voluntary intradermal hepatitis B vaccination program with postvaccination testing was implemented in a 300-bed primary care hospital with a recombinant vaccine packaged in a concentration of 20 micrograms/ml (Engerix B; SmithKline and French Laboratories, Philadelphia, Pa.). METHODS: After informed consent was obtained, 460 employees were vaccinated intradermally over the deltoid muscle by a single employee health nurse at months 0 (initial), 1, 2, and 6, followed by testing for serologic response 1 to 2 months after the final dose. RESULTS: Of 411 employees who completed the entire protocol, 90.5% had seroconversion, as determined by enzyme immunoassay. Twelve of 29 primary nonresponders (41%) had seroconversion after an additional (fifth) intradermal booster injection. Of the primary responders, 84.5% remained seropositive when tested 18 months after the initial vaccination injection. These results are comparable to those of intramuscular vaccination and to the original studies of intradermal vaccination with plasma-derived vaccines that had shown excellent immunogenicity. CONCLUSIONS: Intradermal and intramuscular hepatitis B vaccination programs must be implemented in somewhat different ways, but both can provide excellent protection against hepatitis B viral infection. Even allowing for the additional expense of postvaccination testing and more frequent booster injections, intradermal vaccination greatly reduces the overall costs of hepatitis B vaccination and may therefore increase compliance in many different settings.

Drug-induced granulomatous hepatitis.

Granulomatous hepatitis is a generic histopathologic diagnosis seen in approximately 5 to 10% of liver biopsy specimens. In the past, tuberculosis and sarcoidosis have been most frequently incriminated, although numerous other infectious and noninfectious etiologies have been reported. We have studied 95 cases of granulomatous hepatitis representing 6% of 1500 liver biopsies performed over a period of 10 years. Although sarcoidosis accounted for approximately one-third of these cases, probable and possible associations with medicinal compounds were detected in 29%. Highly suspect drugs include antihypertensive, antirheumatic and analgesic, anticonvulsant, and antimicrobial agents, but any drug may act as a hapten by covalent binding with macromolecular protein. The morphologic features of drug-induced, immunologic granuloma have not been described in detail. In our experience, eosinophils are prominent in the early granulomatous reaction to medicinal compounds and under continued antigenic stimulation are accompanied by plasma cells. Eosinophils are rare to absent in tuberculous hepatic granulomas and, when present in significant numbers, militate strongly against sarcoidosis. Drug-induced granulomas are consistently noncaseous. Although Kupffer cell granulomas have many causes, they are not uncommon hypersensitivity reactions to medicinal drugs and may give rise to clinical illness. Our review suggests that the previous literature does not reflect the magnitude of drug-induced granulomatous hepatic disease and that many cases reported as "granulomatous hepatitis consistent with sarcoidosis," as well as many "undiagnosed" cases, have a drug etiology.

Intravascular mucinosis with mucin emboli and thrombosis accompanying adenocarcinomas.

Three cases of adenocarcinoma that were complicated by nonbacterial thrombotic endocarditis and disseminated intravascular coagulation are described. In two of these cases mucin was demonstrable within vascular channels as well as within the thrombotic vegetations of the cardiac valves. This intravascular mucin was also responsible for vascular occlusion with resultant infarction in such organs as heart and brain. Intravascular mucin of this magnitude has not been previously recorded and mucinous accumulations behaving as thromboemboli with infarcts have not been heretofore described.

Sputum cytology of giant cell interstitial pneumonia.

The purpose of this case report is to illustrate the cytologic findings from a patient who had clinical, radiologic and morphologic evidence of giant cell interstitial pneumonia. Of additional interest is the fact that this patient had had histologically proven desquamative interstitial pneumonia approximately seven years prior to his current admission. A discussion of the relationship between these two entities is also presented. Furthermore, it is emphasized that the presence of multinucleated giant cells alone is a nonspecific finding. However, with proper correlation with clinical history, radiology and other pertinent laboratory studies, one can often minimize the differential diagnosis. This case report points out the usefulness of such an approach in arriving at a specific diagnosis.

Nervous system involvement in type IV glycogenosis.

A 30-month-old girl exhibited the 19th known case of type IV glycogenosis. Extensive involvement of the nervous system was found at autopsy. This represents only the second patient in whom the fine structure of the CNS and skeletal muscle has been described. We have also identified the abnormal polysaccharide in peripheral nerve, a finding that, to our knowledge, has not been reported previously. Our review of the literature indicates that approximately 50% of these patients exhibit signs or symptoms referable to the neuromuscular system. Most clinical and pathologic studies have focused on the severe liver involvement; insufficient attention has been directed toward the nervous system. This emphasizes the need for more detailed neurologic and neuropathologic examinations of children with type IV glycogenosis.