Mycobacterium chelonae hand infection following ferret bite.

We present a case of hand infection caused by Mycobacterium chelonae. The patient was a 58-year-old woman with Type II diabetes mellitus and stage 4 chronic kidney disease. The infection occurred following a ferret bite and had not responded to oral antibiotics in the primary care setting. She developed signs of pyogenic flexor tenosynovitis of the index and middle fingers of her left hand. Laboratory parameters showed high C-reactive protein, raised erythrocyte sedimentation rate and leucocytosis. Ultrasound imaging confirmed the clinical diagnosis. Plain radiographs showed no osseous involvement. The infection was treated with surgical debridement and broad spectrum parenteral antibiotics. The intra-operative tissue specimens were initially negative on aerobic and anaerobic cultures. Following transient improvement of her inflammatory parameters and clinical signs, she developed a recurrence with added features of osteomyelitis of the index and middle finger metacarpal heads on repeat radiographs. A revision surgical debridement of the flexor tenosynovitis and osteomyelitis with specific long-term antibiotic cover has led to resolution of the infection. Extended cultures of the tissue specimens at the regional laboratory confirmed the causative organism to be M. chelonae. To our knowledge, this is the first reported case of M. chelonae infection resulting from a ferret bite. This case reminds us of the need for a high index of suspicion for infection with uncommon pathogens following animal bites, especially in patients with altered immune status.

Irreducible shoulder dislocation - a word of caution.

Anterior dislocation of shoulder is usually amenable to closed manipulation. Failure to achieve satisfactory reduction can be due to soft tissue or osseous interposition. We report a case of irreducible anterior shoulder dislocation with the interposition of the musculocutaneous nerve. This required open reduction and release of the musculocutaneous nerve; which was found to be further trapped by the torn long head of biceps.

Orthopaedic injuries following falls by hospital in-patients.

BACKGROUND: Falls are one of the most frequent episodes on the hospital wards. OBJECTIVE: To identify orthopaedic injuries sustained by in-patients falling on the hospital wards and to find out what treatment these required along with the additional time and cost that this incurred. METHODS: A retrospective analysis of 900 incident forms and case records was undertaken for a 3-year period. Fractures and other soft-tissue injuries sustained and time, place, and mode of injury were noted. Type of fractures sustained and specific treatment required including operative procedure needed were studied. The cost of each treatment and the total cost in terms of time and money were calculated. RESULTS: We identified 42 patients with orthopaedic injuries; 53% of the falls were recorded on medical wards. A poor pre-fall mobility was an important factor in over 80% of the cases, and a variety of medical conditions pre-existed in the elderly ill patients. Eighteen patients (42%) sustained hip fractures, of whom 15 patients (36%) required surgical treatment. There were 9 deaths in total, 5 of them occurred in patients with hip fractures. The cost of treating the injuries amounted to about GBP 70,000. An additional hospital stay of 56 weeks in total was needed, most patients requiring between 1 and 5 weeks of additional stay. CONCLUSIONS: Falls in elderly in-patients can result in a variety of skeletal injuries. These may require major operative procedures and result in significant morbidity and can prove fatal. The treatment of these injuries is a substantial added expenditure to the trust.

Acute locking in revision total knee arthroplasty due to disengagement of the locking screw.

Acute locking of the joint in a replaced knee joint is very rare. This report describes an acute locking episode of a revised modular total knee replacement, occurring more than 2 years after surgery. A disengaged screw from the modular femoral component had lodged in the joint at the inferior pole of the patella and required urgent arthroscopic removal. There was no subsequent failure of the stem-condylar junction, nor loosening of the femoral component.

CD40 Ligand--an anti-apoptotic molecule in Hodgkin's disease.

The expression of CD40L was investigated in HD involved lymph nodes by flow cytometry (FCM) and reverse transcriptase polymerase chain reaction (RT-PCR). Also an investigation of the role of CD40L in upregulation of the anti-apoptotic gene BclxL in a Hodgkin's disease (HD) derived cell line was undertaken. HD patients (n = 18) had significantly higher numbers of activated CD4+ and CD8+ T cells in the tumor microenvironment as compared to controls (n = 8). HD patients also demonstrated higher numbers of CD4+, CD8+ and CD19+ lymphocytes co-expressing CD40L as compared to controls. The CD40L signal was consistently and significantly upregulated in HD patients (n = 5) as compared to controls (n = 3) at the mRNA level. RT-PCR and FCM analysis revealed that soluble CD40L upregulated BclxL levels in the Fas-sensitive HD cell line HDLM2. We conclude that CD40L can act as an important anti-apoptotic molecule by upregulating BclxL expression in Reed-Sternberg cells of HD and may be partly responsible for their survival 'in-vivo'.

Circulating levels of TNF alpha and TNF receptor superfamily members in lymphoid neoplasia.

We have correlated the serum levels of TNF alpha and soluble TNF receptor superfamily members with clinico-pathologic parameters in patients of Hodgkin's disease (HD, N = 26) and non-Hodgkin's lymphoma (NHLs, N = 35). HD patients had significantly higher levels of TNF alpha, sTNFRI, and sTNFRII in serum while NHL patients had significantly higher levels of sTNFRI, sTNFRII, sCD27, and sFas as compared to controls. In NHL patients the levels of sCD27 correlated directly and significantly with the high-stage disease, bone marrow involvement, lymph nodal presentation, and serum LDH levels. Similarly in NHL patients, levels of sFas also correlated directly and significantly with the presence of high stage disease. HD patients with B symptoms had significantly higher levels of sTNFRII.

Intra-tumoral cytolytic cells: pattern of distribution in B-cell non Hodgkin s lymphoma.

Non-Hodgkin s lymphomas (NHLs) constitute a heterogeneous group of lymphoid neoplasms and a majority of them in India are of B-cell phenotype. Varying numbers of T lymphocytes and natural killer (NK) cells are consistently present within the lymph nodes (LNs). The role of these reactive cells is becoming understood. TIA-1 is a cytotoxic granule associated RNA binding protein, the expression of which is restricted to cytotoxic T lymphocytes (CTLs) and NK cells. Snap frozen lymph node biopsies obtained from 41 B-cell NHLs were localized for intra-tumoral TIA-1 + cytolytic cells by immunohistochemistry. Distribution of T cell subsets and NK cells were also quantified. Cells expressing TIA-1 antigen was observed in all the cases, seen as a strong granular cytoplasmic signal. Results indicate significantly higher number of TIA-1 cytolytic cells outside (periphery of the follicle and interfollicular areas) than within the neoplastic follicle in follicular lymphomas (p<0.001). In small lymphocytic lymphomas, cytolytic cells were mainly seen as uniformly scattered single cells, distributed throughout the tumor environment. In mantle cell and diffuse large B-cell lymphomas these were most often seen as small clusters and less frequently as singly scattered cells. Higher numbers of CD4 + than the CD8 + T cells were observed in most cases. Contrary to the follicles in follicular hyperplasia, CD57 + NK cells were predominantly observed outside the neoplastic follicle in follicular lymphomas (FLs). These results outline specific interactions between the potential anti-tumoral cytolytic and the malignant cells of B-cell NHLs.

High cytosolic pool of p75 TNF receptors and delayed surface downmodulation by mononuclear cells from non-hodgkin's lymphoma patients.

Analysis of the expression of TNF-Rs on fresh peripheral blood mononuclear cells (PBMNC) by Scatchard analysis showed that Gr I (stages I and II) but not Gr II (stages III and IV) NHL patients have a significantly higher expression of surface TNF-Rs than normal controls. A rapid decrease in the binding of radiolabelled anti-p75 TNF-R Mab which gradually increased after 16 h was seen in normal controls, while NHL patients showed a rapid increase in the binding of the Mab after activation of cells and a decrease in binding was observed only after 24 h. Western blot analysis for normal controls showed a weak presence of the 42 kDa fragment only, while the cytosolic extracts from fresh PBMNCs of NHL patients showed presence of both intact p75 TNF-R, as well as a 42 kDa fragment corresponding to a soluble form of p75 TNF-R. Our results suggest that increased cytosolic pools of TNF-R in NHL patients might contribute to a rapid increase in its surface expression following activation of cells.

Ceramide-induced apoptosis in fas-resistant Hodgkin's disease cell lines is caspase independent.

We investigated whether cell-permeable, synthetic ceramide (C6 ceramide) could induce apoptosis in Fas-resistant Hodgkin's disease (HD)-derived cell lines. Despite strongly expressing the Fas-receptor, two of three HD-derived cell lines were resistant to Fas-mediated apoptosis. This resistance to Fas could not be attributed to differential Fas isoform generation patterns between the Fas-resistant and the Fas-sensitive cell lines. The Fas-resistant cell lines did not demonstrate the presence of Fas exon 8 deletion. Bcl-2 and BclxL levels were comparable between the Fas-resistant and the Fas-sensitive cell lines. C6 ceramide could induce apoptosis in both Fas-resistant cell lines and this was associated with a decrease in BclxL level. Caspase-1, caspase-3, or pan-caspase inhibitors could not prevent ceramide-induced apoptosis. Furthur, ceramide treatment did not lead to cleavage of caspase 3 or poly(ADP-ribose) polymerase, but caused a loss in mitochondrial transmembrane potential which could not be prevented by caspase inhibitors. Thus, we conclude that ceramide-induced apoptosis in Fas-resistant HD cell lines is caspase independent.

IL-12 and IL-2 potentiate the in vitro tumor-specific activity of peripheral blood cells from cervical cancer patients.

We have carried out a detailed analysis of the cellular immune functions of cervical cancer patients in comparison with healthy controls. It has been observed that the freshly isolated peripheral blood mononuclear cells (PBMC) exhibit natural cytotoxicity (NC) against a number of targets including tumor cells, mainly delivered by NK cells, which are non-adoptive and MHC unrestricted. Upon stimulation with cytokines like IL-2, IL-7, IL-12, IL-15 and interferons, PBMC acquire lymphokine activated killer (LAK) activity which enables them to lyse a wide range of targets including fresh tumor cells and virally infected cells. We compared the effect of IL-2 and IL-12 on enhancement of NC of PBMC from cervical cancer patients. IL-12 stimulated cultures (CD3+, CD56+) exhibited significant levels of tumoricidal activity. IL-2 stimulated lytic activity sustained even after 10 days while that of IL-12 stimulated cells declined after 6 days. Activation of PBMC was marked by increase in the expression of activation marker CD45RO and adhesion molecules LFA-1alpha, ICAM-1 and CD44. Addition of IL-12 to IL-2 stimulated cultures further enhanced the degree of lytic activity. Our data, thus, provide an evidence that PBMC from cervical cancer patients can be stimulated in response to cytokines and local or systemic treatment with low doses of cytokines may help to yield a better immune response against virus infected tumor cells in cervical cancer.

Immune functions, clinical parameters and hormone receptor status in breast cancer patients.

We have carried out a detailed analysis of the cellular immune functions of breast cancer patients in comparison with healthy controls. A possible correlation between immune and clinical parameters was analysed in 50 breast cancer patients. Immune parameters, natural killer cell and T lymphocyte functions and the numbers of circulating T lymphocytes were analysed against the clinical parameters comprising the tumour burden, the stage of the disease and the expression of hormone receptors on the tumour. In order to analyse the immune function data effectively, low responders were identified with stringent cut-off values. Considerably higher proportions of low responders were found among the patient population. Elevated numbers of circulating T lymphocytes and CD3-directed cytolysis correlated with the expression of oestrogen receptors independently of the clinical/histological parameters.

Expression of Fas and Fas ligand in Hodgkin's disease.

Fas and Fas ligand expression were investigated in twenty two cases of classical Hodgkin's disease (HD) by immunohistochemistry. While Reed-Sternberg (RS) cells in 7/22 (32%) cases expressed Fas ligand, reactive lymphoid cells expressed Fas ligand in only 2 (9%) cases. In 20/22 (91%) cases, the RS cells expressed Fas. A higher proportion of RS cells in the nodular sclerosis subtype expressed Fas as compared to the mixed cellularity subtype. In 18/22 (82%) cases, Fas expression was also noted in the reactive lymphoid cells. In eight cases, the reactive lymphoid cells were also analyzed by flow cytometry and a majority of them were CD4+CD45RO+. Most of these activated T-cells expressed Fas but were negative for Fas Ligand. To investigate the co-expression of Fas and Fas Ligand in the RS cells, six cases were subjected to Fas and Fas ligand immunostaining on consecutive sections. The co-expression was documented in the RS cells in four of six cases. These six cases with expression of both Fas and Fas ligand were investigated for the incidence of apoptosis. There was no statistically significant relationship between expression of Fas on reactive cells, expression of FasL on RS cells and the proportion of apoptotic reactive cells. In all these cases apoptosis was not observed in the RS cells. Thus Fas - FasL interactions may not lead to apoptosis of the RS cells.

Altered release of tumor necrosis factor and its soluble receptor in non-Hodgkin's lymphoma patients.

Increased expression and elevated serum levels of tumor necrosis factor-alpha (TNF-alpha) have been shown to be associated with the presence of constitutional B symptoms and poor prognosis in non-Hodgkin's lymphoma (NHL) patients. Soluble TNF receptors (sTNF-R) are suggested to act as biological buffers in inflammatory conditions by binding and inactivating increased circulating TNF. Whereas studies have shown elevated TNF to be correlated with B symptoms, similar studies showing the status of soluble receptor release in these patients have not been conducted. Here, we show that there is increased soluble p75 TNF receptor release from peripheral blood mononuclear cells (PBMNC) in NHL patients in the early stages of the disease but it is severely depressed in patients with advanced disease. Decreased release is associated with presence of B symptoms in these patients. All NHL patients also show increased TNF secretion and a decreased rate of receptor release with time compared with healthy controls. These findings imply that decreased sTNF-R receptor release, in addition to increased TNF secretion, is also important in predisposing the patients to B symptoms. This opens up the possibility of the use of sTNF-Rs as a therapeutic tool to counter increased TNF and alleviate systemic symptoms in these patients and also as a marker for the progression of the disease.

Characterization of a murine monoclonal antibody against human esophageal squamous cell carcinoma-associated antigen.

A murine monoclonal antibody (MAb) 2G3 of the IgG1 type was raised using the human esophageal squamous cell carcinoma (SCC) cell line TE-2. Immunoblotting with 2G3 indicated that the antigen recognized by 2G3 has a molecular weight of 34 kD. Its activity was evaluated by immunoperoxidase and immunofluorescence on frozen and paraffin sections of various normal tissues, normal and benign tumors as well as various established cell lines. The pattern of reactivity revealed that the antigen recognized by 2G3 was expressed mainly by esophageal SCC. The only exception was represented by malignant breast tumors, where it reacted weakly. Scatchard analysis using 125I-labelled 2G3 showed that TE-2 has approximately 7.5 times more binding sites than the MCF-7 breast cancer cell line. The use of this new MAb is therefore proposed for the histopathological diagnosis of esophageal SCC.

Natural killer cell function and genetic instability in unaffected individuals from breast cancer families.

Several recent reports highlight the importance of modifying factors in determining the risk for cancer of a person carrying a mutant allele of a tumour susceptibility gene. The study of two such risk modifying factors namely, natural killer (NK) cell function and constitutional cytogenetic anomalies in members of families with familial breast cancer is presented in this paper. We observed that, compared to healthy controls, a significant proportion of unaffected persons from breast cancer families not only display lower NK cell function or genetic instability alone, but also in conjunction. The significance of these observations is discussed. We propose that amongst the unaffected members, persons with lower NK cell function as well as constitutive cytogenetic anomalies may be at a higher risk for cancer. The need for a set of suitable biomarkers to identify individuals at high risk from familial breast cancer families has been recognized for many years. Constitutional cytogenetic anomalies, otherwise seen in breast tumours, have also been observed in lymphocyte cultures from unaffected persons from such families. Lowered NK cell function has previously been demonstrated in first degree relatives of cancer patients. Both these parameters have been implicated in determining the risk of developing malignancy. In the present study these aspects have been investigated simultaneously in order to assess their utility as potential biomarkers.

CD40-ligation-mediated protection from apoptosis of a Fas-sensitive Hodgkin's-disease-derived cell line.

Modulation of Fas expression and function by CD40 ligation was investigated in the Fas-sensitive human Hodgkin's disease cell line HDLM2. The recombinant human trimeric soluble CD40L (sCD40L) protected this cell line from apoptosis induced by an agonistic Fas antibody at all concentrations tested. sCD40L also protected HDLM2 when added up to 2 h after Fas ligation. Apoptosis induced by a cell-permeable synthetic ceramide could not be prevented by sCD40L. Thus, CD40 ligation is likely to intervene in the early phases of the Fas signal transduction pathway. When CD40 ligation preceded Fas ligation, it rendered the cells refractory to Fas-induced apoptosis. sCD40L-mediated protection could not be attributed to reduction in surface Fas expression, increase in Bcl-2 levels or to increase in the levels of soluble Fas isoforms.

Studies on functional status of circulating lymphocytes in unaffected members from cancer families.

That the inheritance of mutations in tumor susceptibility genes alone cannot determine risk for developing cancer is now well accepted. Immune functions have long been recognized as one of the important risk modifying factors in this regard. In an attempt to develop a multiparametric approach to identify high risk individuals from cancer families, we have examined NK cell function in unaffected members from familial breast cancer families. We have also carried out a parallel study of T lymphocyte functions in these individuals. Our studies demonstrate a significantly lower NK cell activity in members from cancer families. T lymphocyte activity also showed a similar trend, with the unaffected members demonstrating a notably lowered T lymphocyte function. In addition the data from patients reveals differential sensitivity of NK and T lymphocyte function to the disease phenotype. Implications of these observations are discussed.

Impaired T lymphocyte function and differential cytokine response pattern in members from cancer families.

In an attempt to understand the basis of lowered natural killer (NK) and T cell functions in unaffected members from cancer families, we investigated cytotoxic T lymphocyte function (CD3-directed lysis) and the ability of the lymphocytes to respond to cytokines such as IL-2, IFN-alpha and IL-12. We observed lower CD3-mediated cytotoxic activity in these individuals supported by significantly lower numbers of circulating CD3+ lymphocytes. The cytokine treatment studies revealed impaired response to IFN-alpha and IL-12 in unaffected members and breast cancer patients. The observations presented herein not only reinforce our earlier finding that lower NK and T lymphocyte function may be a feature of cancer families, but also suggest that such impaired responses may be one of the factors contributing to lower cytotoxic potential of the circulating lymphocytes.