Gestational choriocarcinoma transmission following multiorgan donation.

An accidental transmission of placental choriocarcinoma (CC) from a multiorgan donor to four recipients is reported. The donor was a 26-year-old pregnant woman, died from a cerebral hemorrhage. Histological examination demonstrated the presence of a placental CC. Diagnosis of CC transmission was established on the basis of an increase of human chorionic gonadotrophin hormone (hCG) level. The recipient of combined pancreas-kidney is still in complete remission 2 years after the beginning of chemotherapy without removal of the grafted organs which show optimal function. The recipient of a single kidney was rapidly transplantectomized and treated with actinomycin. At 2 years, she remains in remission. Liver recipient showed intestinal metastasis and died from digestive hemorrhage after an initial response to chemotherapy. Heart recipient had an initial remission under EMA-CO, but at the last report, he showed diffuse metastasis. Published reports on CC transmission are rare. The long-lasting remission of our pancreas-kidney recipient and her good outcome after 2 years make our observation original. Moreover, the high rate of transmission demonstrates the high malignant potential of CC in immunosuppressed patients. Chemotherapy combined or not with transplantectomy in case of nonvital organ, should be discussed.

Chronic lymphocytic leukemia: a hazardous condition before kidney transplantation.

Long-term survival of patients with chronic lymphocytic leukemia (CLL) is over 10 years, and such patients are thus potential kidney recipients in the case of superimposed end-stage renal disease. However, the renal and patient outcome in this condition is unknown. We report the charts of four patients with CLL who were engrafted in France with a deceased-donor kidney and underwent routine triple immunosuppressive therapy. The results show that these patients developed severe infectious episodes (fatal in one case) and tumoral complications including rapid progression of CLL in two cases. Moreover, the graft may be infiltrated and damaged by monoclonal B cells: one patient lost his graft 14 months after transplantation. Various therapeutic options (modifications of the immunosuppressive regimen, anti-CD20 antibodies, irradiation of the graft) showed little (if any) efficacy. Therefore, we believe that CLL is a too hazardous condition to envisage solid organ transplantation with a routine immunosuppressive regimen, and we propose a more appropriate approach.

[Leukocytoclastic vasculitis with severe renal involvement following Parvovirus B19 primary infection]. / Vasculite leucocytoclasique compliquée d'une atteinte rénale grave au décours d'une primo-infection à Parvovirus B19.

BACKGROUND: Leukocytoclastic vasculitis following Parvovirus B19 primary infection has occasionally been reported in children but it occurs rarely in adults. We present an original case report with severe renal complications. PATIENTS AND METHODS: A 33-year-old man presented with fever and eruption of the abdomen and members. Papules and vesiculopustules were associated with oral and genital ulcerations. These lesions subsequently became purpuric and necrotic. Histological analysis confirmed the diagnosis of pustulous leukocytoclastic vasculitis with IgA deposits. Laboratory investigations showed elevated sedimentation rate, hepatic cytolysis and renal impairment (hematuria, leucocyturia and proteinuria 1.5 g/24 hours). Anti-parvovirus B19 IgM were positive. Three months after the eruption resolved, IgM were undetectable while anti-parvovirus B19 IgG appeared. Renal injury progressively worsened: elevation of proteinuria (5 g/24 hours) and diminution of creatinine clearance (51 ml/min). Renal biopsy showed glomerulonephritis with mesangial IgA deposits. Major proteinuria persisted one year after the disappearance of dermatological lesions in spite of ACE inhibitor treatment. DISCUSSION: The role of Parvovirus B19 has been suspected as an aetiological agent in many kinds of vasculitis, e.g. polyarteritis nodosa, Wegener's disease and leucocytoclastic vasculitis. In this case report, the detection of specific IgM and the absence of other factors associated with vasculitis are consistent with a causal role of Parvovirus B19. In previously published cases, the prognosis of parvovirus B19-associated vasculitis does not seem to differ from that of idiopathic vasculitis. To our knowledge, this is the first case exhibiting concomitant and persistent severe renal involvement.

[Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) in patients with solid organ transplantation: a clinical, neurophysiological and neuropathological study of 4 cases]. / Polyradiculonévrite chronique chez des patients avec une greffe d'organe solide: une étude clinique, neurophysiologique et neuropathologique de 4 cas.

INTRODUCTION: Chronic inflammatory demyelinating polyradiculoneuropathy (CIDP) rarely develops in patients with solid organ transplantation. PATIENTS AND METHOD: We describe the clinical, biological, electrophysiological and neuropathological features of 4 patients with solid organ transplantation who developed CIDP. Two patients had liver transplantation, one had kidney transplantation and one had lung transplantation. RESULTS: All 4 patients developed in the months following transplantation a syndrome that fulfilled criteria for definite CIDP. All patients had immunosuppressive therapy, with ciclosporin + prednisolone in 2 cases, tacrolimus in 1 case and azathioprine + prednisolone + ciclosporin in one case. One patient had chronic HCV and HBV infection. Treatment with intravenous immune globulin (IVIG) and/or a change in immunosuppressive therapy improved the neuropathy in all cases. CONCLUSION: CIDP is a rare and potentially treatable condition that should be considered in all patients with solid organ transplantation who develop a rapidly disabling sensorimotor polyneuropathy.

Novel techniques, standardization tools to enhance reliability of acoustic rhinometry measurements.

Acoustic rhinometry measurements are influenced by factors related to subject posture, breathing, inclination and positioning of the wavetube, leaks and distortion at the nostril-nose adapter connection and ambient noise. We present simple techniques to control these errors. Thus, gel on contoured nose adapters, shadow tracing to maintain posture, laser homing for wavetube alignment, are all integrated into a practical scheme that is easy to implement and causes minimum discomfort to subjects. Repeatability improved to below 3% coefficient of variation (CV) in non decongested subjects when trained operators used all the techniques together viz. gel on nose adaptors, shadow tracing, laser homing. In a factorial experiment, repeated measurements were made on subjects over two consecutive days with operator training and standardization tools as variables. An analysis of variance identified the most important factors to be gel on contoured nose adapters, operator training and control of breathing. With gel, the mean CV between readings was 5.8%, measurement time 30.3 seconds. The tools, especially gel and shadow tracing, helped untrained operators achieve performance levels that were more comparable with trained operators. Reproducible curves could be taken rapidly. Thus a significant difference of 31.2 seconds between untrained and trained operators reduced to 12.6 seconds using tools. These techniques significantly improve the reliability, speed and ease of doing repeated acoustic rhinometry measurements and thus the quality of data generated in nasal studies.

Nasal histamine challenge: a reproducible model of induced congestion measured by acoustic rhinometry.

We describe the development of a clinical model of nasal congestion using a fixed dose histamine challenge in normals. The objective was to use histamine to induce a similar degree of nasal congestion as a natural common cold (from unpublished data of 250 cold sufferers) and thus establish a rapid screening system for decongestant drug effects. Sixtynine normal subjects were challenged with histamine diphosphate (300 micrograms/nostril) on 2 visits. Thirtytwo subjects were identified showing reproducible baseline values (< 15%CV (coefficient of variation)) and adequate nasal congestion (minimum 20%) without excessive sneezing. Reproducibility was evaluated in them post challenge using acoustic rhinometry and rhinomanometry. Twentythree subjects showed a variation < 25%CV of nasal volume over multiple visits in a 5 month period. The average reduction in nasal volume and airflow 15 minutes post challenge was 32% and 41% respectively. Acoustic rhinometry values were less variable than rhinomanometry values. Negligible differences (< 2%) in histamine response over visits and similar correlation between measured values at first, second and last visits indicate that 2 visits are adequate to evaluate response reproducibility in a selected population. We conclude that it is feasible to develop a robust clinical model of nasal congestion using histamine.

Methods of recording and analysing cough sounds.

Efforts have been directed to evolve a computerized system for acquisition and multi-dimensional analysis of the cough sound. The system consists of a PC-AT486 computer with an ADC board having 12 bit resolution. The audio cough sound is acquired using a sensitive miniature microphone at a sampling rate of 8 kHz in the computer and simultaneously recorded in real time using a digital audio tape recorder which also serves as a back up. Analysis of the cough sound is done in time and frequency domains using the digitized data which provide numerical values for key parameters like cough counts, bouts, their intensity and latency. In addition, the duration of each event and cough patterns provide a unique tool which allows objective evaluation of antitussive and expectorant drugs. Both on-line and off-line checks ensure error-free performance over long periods of time. The entire system has been evaluated for sensitivity, accuracy, precision and reliability. Successful use of this system in clinical studies has established what perhaps is the first integrated approach for the objective evaluation of cough.

Evaluation of antitussive agents in man.

Methodology to evaluate the efficacy of antitussive drugs rely largely on subjective methods and cough counts. There are few studies in cough due to natural disease especially using objective techniques. This paper presents data from a series of randomized, double blind, placebo controlled clinical trials in cough due to both chronic bronchopulmonary disease and acute upper respiratory tract infections. In these studies, cough was quantified using a standardized and validated computerized system for the acquisition and multidimensional analysis of the cough sound. Key objective parameters like cough counts, intensity, latency and total effort expended were studied. Guaiphenesin and bromhexine showed significant expectorant effects in patients with productive cough due to chronic bronchopulmonary disease. Differences were observed in speed of action, and objective and subjective measures, that probably indicate differences in drug action. More recently, three studies evaluated the antitussive drug dextromethorphan in non-productive cough due to uncomplicated upper respiratory tract infections. Reproducible cough suppressant effects were demonstrated after a single 30 mg dose using objective measures of cough counts, latency and total effort. These results establish the sensitivity and robustness of the cough quantitation methodology in the objective evaluation of cough treatments.